College  of  S^f)v^itiani  anb  burgeons! 
Hihravp 


i.[y\r\\r 


DISEASES  OF  THE  STOMACH 


WITH  SPECIAL  EEFEEENCE  TO  TREATMENT 


BY 

CHARLES  D.  AARON,  Sc.D.,  M.D. 

PROFESSOR    OF    GASTROENTEROLOGY   AND    ADJUNCT    PROFESSOR    OF    DIETETICS    IN    THE    DETROIT   COLLEGE 

OF    medicine;    PROFESSOR    OF    DISEASES    OF    THE    STOMACH    AND    INTESTINES    IN    THE 

DEXROIT    POST-GRADUATE    SCHOOL    OF    MEDICINE;    CONSULTING 

GASTROENTEROLOGIST   TO    HARPER    HOSPITAL 


WITH   42    ILLUSTRATIONS   AND   21    PLATES 


LEA   &   FEBIGER 

PHILADELPHIA    AND    NEW    YORK 


Entered  according  to  the  Act  of  Congress,  in  the  year  1911,  by 

LEA    &    FEBIGER 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


to 

05 


o 

o 


o 


DEDICATED   TO 

PROFESSOR  ADOLF  SCHMIDT,  M.D. 

DIRECTOR   OF  THE   MEDICAL  CLINIC  AT  THE  UNIVERSITY    OF   HALLE 

IN   RECOGNITION   OF   HIS    INVALUABLE    CONTRIBUTIONS 

TO   THE 

SCIENCE    OF    GASTROENTEROLOGY 


^3 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofstomacOOaaro 


PREFACE 


In  this  work  the  author  has  endeavored  to  cover  the 
medical  aspects  of  gastric  disorders  in  such  a  manner  as  to 
answer  the  actual  needs  of  the  practitioner.  To  keep  the 
book  within  convenient  limits,  it  has  been  restricted  to  the 
useful  and  suggestive  aspects  of  present  knowledge  on 
the  subjects  discussed,  the  purely  speculative  being  rigor- 
ously excluded.  It  is  intentionally  practical  and  therapeutic, 
hence  etiology,  symptomatology,  pathology,  and  diagnosis 
are  introduced  only  in  so  far  as  they  are  necessary  to  an 
understanding  of  the  methods  of  treatment  proposed.  In 
addition  to  the  chapter  on  Medication,  due  attention  has 
been  given  to  the  use  of  Antilytic  Serum  and  Bacterial 
Vaccines.  Care  has  been  exercised  to  reflect  the  latest 
progress  in  this  rapidly  advancing  department.  Because  of 
recent  discoveries  in  the  physiology  of  digestion,  a  chapter 
has  been  added  upon  this  subject,  but  from  the  viewpoint 
of  the  chnician  rather  than  that  of  the  physiologist. 

The  chapter  on  Examination  of  the  Stomach  Contents 
includes  those  tests  which,  in  the  opinion  of  the  author, 
will  best  assist  the  practitioner  in  diagnosis  and  treat- 
ment. With  regard  to  surgical  treatment,  no  more  has 
been  attempted  than  to  give  the  indications.  Although 
surgery  is  indicated  in  many  cases  of  stomach  disease,  the 
utmost  caution  is  necessary  to  avoid  useless  or  injurious 
intervention. 

Inasmuch  as  a  large  number  of  gastric  disorders  may  be 
classed  as  neuroses,  emphasis  has  been  placed  upon  this 
phase  of  the  general  subject.  It  is  accordingly  given 
priority  in  position,  and  discussed  under  various  subdivi- 
sions— as  neuroses  resulting  in  sensory  disturbances,  those 


VI  PREFACE 

responsible  for  motor  disturbances,  and  those  to  which 
derangements  of  the  secretory  function  may  be  traced. 
The  attention  of  the  reader  is  drawn  to  pathologic  condi- 
tions due  to  ptosis  of  the  abdominal  viscera,  as  the  author 
has  obtained  good  results  in  the  treatment  of  gastroptosis 
by  employing  the  principle  of  mechanical  support.  Achylia 
Gastrica  is  considered  under  the  head  of  Chronic  Gastritis 
because  the  latter  involves  the  diminution  and  eventual 
cessation  of  gastric  secretion. 

The  author  wishes  to  make  acknowledgment  of  his 
indebtedness  to  the  many  American  practitioners  who  have 
contributed  so  greatly  to  the  advancement  of  gastro- 
enterology, and  to  the  foreign  writers  whose  scientific 
achievements  have  received  approval  nowhere  more  cor- 
dially than  in  this  country. 

C.  D.  A. 

Detroit,  Michigan,  1911. 


CONTENTS 


CHAPTER  I 

The  Physiology  of  Digestion 

Salivary  Digestion;  Movements  of  the  Stomach;  Gastric  Digestion; 

Intestinal  Digestion 17-30 

CHAPTER  II 

Examination  of  the  Stomach  Contents 

Test  Meals;  Macroscopic  Examination  of  Stomach  Contents; 
Chemic  Examination  of  Stomach  Contents;  Quantitative 
Analysis;  Examination  of  Enzymes;  Carbohydrate  Diges- 
tion in  the  Stomach;  Blood  in  Gastric  Contents;  Examination 
of  Feces;  Indirect  Methods  of  Gastric  Analysis;  Skin  Reaction 
in  Carcinoma;  Motor  Function  of  the  Stomach;  Permeability 
of  the  Pylorus;  Microscopic  Examination  of  Stomach  Contents; 
Changes  in  Gastric  Secretion  due  to  Pathologic  Conditions     .         31-76 

CHAPTER  III 

Diet  in  Gastric  Diseases 

Composition  of  Foods;  Heat  Value  of  Foods;  Dietary  Regulations 
and  Lists;  Meat;  Fat;  Milk;  Cheese;  Bread;  Potatoes;  Rice; 
Green  Vegetables;  Liquors;  Fruit;  Sugar;  Spices;  Water; 
Alcohol;  Tea  and  Coffee 77-105 

CHAPTER  IV 

Artificial  Food  Preparations 

Preparations  of  Animal  Protein,  Vegetable  Protein,  Milk  Protein, 
Egg  Protein;  Preparations  from  Carbohydrates;  Dextrinated 
Flours;  Mixed  Nutritive  Preparations;  Preparations  Contain- 
ing Fat;  Milk  Preparations;  Stimulating  Preparations;  Rela- 
tive Value  of  Meat  Extracts 106-117 

CHAPTER  V 

Lavage  of  the  Stomach 

Indications,    Contraindications,    and    Technique;    The    Stomach 

Douche     118-132 


viii  CONTENTS 

CHAPTER  VI 

Massage — Electricity 

Massage  of  the   Stomach;   Electric   Treatment   of  the  Stomach, 

Intraventricular  and  Extraventricular       .      .      ...      .      .      .      133-145 

CHAPTER  VII 

HtDROTHERAPEUTICS — ^IlXERAL   WaTERS 

Hydriatic  and  Thermic  Treatment  of  the  Stomach;  Half  Baths, 
Cold  and  Warm  Packs,  Prolonged  Baths,  Compresses, 
Douches;  Mineral  Waters — Alkaline  Chlorine,  Sodium  Chlo- 
ride, Alkaline  Carbonated,  Ferruginous,  and  Bitter;  Mineral 
Baths,  Sea  Baths,  and  Climatic  Cures;  American  ^Mineral 
Waters 146-165 

CHAPTER  VIII 

Medicatioxs 

Hydrochloric  Acid;  Pepsin;  Pancreatin;  Alkalies;  Bismuth;  Strych- 
nine and  the  Bitters;  Silver  Nitrate;  Gastric  Sedatives;  Gas- 
tric Anodynes;  Drugs  Used  Incidentally  in  Gastric  Disorders; 
Antiseptics;  Emollients 166-201 

CHAPTER  IX 

Indications  for  Surgical  Intervention 

Gastroenterostomy  and  Gastrostomy;  Gastric  Ulcer;  Perforation 
in  Gastric  Ulcer;  Pyloric  Stenosis;  Acute  Dilatation  of  the 
Stomach;  Gastric  Tetany;  Perigastritis;  Hourglass  Contrac- 
tion; Carcinoma 202-219 

CHAPTER  X 

Alterations  in  the  Position  of  the  Stomach  and  Other  Abdominal 

Organs  :  Gastroptosis — Enteroptosis — Nephroptosis — 

Hepato  ptosis — Splenoptosis 

Pathology  and  Symptoms  of  Gastroptosis  and  Enteroptosis;  Palpa- 
tion of  the  Ividney;  Treatment;  Technique  of  Nutrition; 
Exercise  and  Massage;  Electrotherapeutics;  Hydrothera- 
peutics;  Mechanical  Treatment  of  Enteroptosis;  Medicinal 
Treatment;  Surgical  Treatment 220-258 


CONTENTS  IX 


CHAPTER  XI 

Motor    Neuroses:     Hypermotility — Peristaltic    Unrest — Carpio- 

SPASM — Pylorospasm — Eructations — Pneumatosis — Vomiting 

— RuxMiNATioN — Regurgitation — Pyloric  Insufficiency — 

Singultus  Gastricus 

Nervous  Affections  of  the  Stomach;  Hypermotihty;  Peristaltic 
Unrest  of  the  Stomach;  Cardiospasm  and  Pylorospasm,  with 
Reference  Especially  to  Treatment  by  Dilatation;  Nervous 
Eructations  (Aerophagy);  Pneumatosis  (Drum-belly);  Nervous 
Vomiting;  Rumination,  Merycism;  Regurgitation;  Insuffi- 
ciency of  the  Pylorus;   Singultus   Gastricus 259-281 

CHAPTER  XII 

Sensory  Neuroses  :    Gastralgia — Hyperesthesia — Gastralgokenosis 
— Nausea — Bulimia — Akoria — Anorexia — ^Eye  Strain 

Gastralgia,  Cardialgia,  Gastrodynia,  Neuralgia  of  the  Stomach; 
Gastric  Hyperesthesia;  Gastralgokenosis;  Nervous  Nausea; 
Bulimia;  Akoria;  Nervous  Anorexia;  Gastric  Neuroses,  and 
Eye  Strain 282-294 

CHAPTER  XIII 

Nervous  Dyspepsia:     Neurasthenia  Gastrica 

Relation  to  Disturbances  of  Other  Organs,  Notably  Appendicitis; 
The  Rest  Cure;  Nutrition — Lactovegetable  Diet;  Physical 
Treatment;  Mineral  Waters;  Sea  Water  Therapy;  Drug 
Treatment;  Vicarious  Surgery 295-310 

CHAPTER  XIV 

Secretory  Neuroses:     Hyperacidity — Hyperchlorhydria — Super- 
acidity 

Hyperchlorhydria;  Chronic  Acid  Gastritis;  Treatment  of  Hyper- 
acidity, Hyperchlorhydria,  and  Acid  Gastritis — Fats  and  Oils; 
Salt-free  Diet;  Silver  Nitrate;  Atropine;  Hydrogen  Peroxide; 
AlkaUes • 311-331 

CHAPTER  XV 

Secretory    Neuroses    (continued) :    Hypersecretion — Gastrorrhea — 
Gastrosuccorrhea — Gastrochylorrhea 

Intermittent  or  Periodic  Hypersecretion;  Acute  or  Intermittent 
Gastrorrhea;  Chronic  Gastrorrhea — Reichmann's  Disease; 
AUmentary  Hypersecretion 332-345 


X  CONTENTS 

CHAPTER  XVI 

Acute  Gastritis  :    Simple — -Infectious — Toxic — Phlegmonous 

Simple  Acute  Gastritis;  The  Best  Method  of  Cleansing  the  Stomach; 
The  Use  of  Emetics;  Gastro-enteritis  as  a  Complication;  Acute 
Infectious  Gastritis;  Toxic  Gastritis;  Phlegmonous  Gastritis — 
Pathology,  etc 346-361 

CHAPTER  XVII 

Chronic  Gastritis:    Subacid  Gastritis — Anacid  Gastritis — Achylia 

Gastrica 

Chronic   Gastritis    (Chronic   Gastric   Catarrh);   Achylia   Gastrica; 

Treatment  of  Gastritis  and  Achylia  Gastrica 362-392 

CHAPTER  XVIII 

Motor    Insufficiency:     Atony    (Myasthenia) — Dilatation    (Ischo- 
chymia,  Gastrectasis) — Stenosis  of  the  Pylorus 

Motor  Insufficiency  of  the  First  Degree;  Motor  Insufficiency  of  the 

Second  Degree;  Acute  Dilatation  of  the  Stomach     ....     393-417 

CHAPTER  XIX 

Gastric  Ulcer:    Ulcus  Ventriculi — Round  Ulcer — Peptic  Ulcer — 
Perforating  Gastric  Ulcer 

Situation;  Frequency;  Sex  Predisposition  and  Age;  Vomiting; 
Perforation;  Appetite;  Leube-Ziemssen  Treatment;  Lenhartz 
Treatment;  Duodenal  Alimentation;  Medicinal  Treatment; 
Antilytic  Serum;  Bacterial  Vaccines;  Surgery 418-459 

CHAPTER  XX 

Gastric  Hemorrhage — Gastrorrhagia 

Differential  Diagnosis;  Treatment  by  Lavage;  Diet;  Ergot;  Gelatin; 
AdrenaHn;  Bismuth  Salts;  EscaUn;  Silver  Nitrate;  Analgesics; 
Hematinics;  Operative  Treatment        460-476 

CHAPTER  XXI 

Erosions — Perigastritis 

Erosions — Predisposition;  Dietetic,  General  and  Local  Treatment; 
Perigastritis — Development;  Form;  Early  Diagnosis;  Treat- 
ment         477-486 


CONTENTS  xi 

CHAPTER  XXII 

Arteriosclerosis — Syphilis — Tuberculosis 

Arteriosclerosis — Manifestations  and  Pathology;  Treatment  by 
Means  of  Inorganic  Blood  Salts,  or  Serum;  Syphilis — Advan- 
tages of  Hypodermic  Medication;  Salvarsan;  Tuberculosis — 
Forms  and  Treatment 487-502 

CHAPTER  XXIII 

Tumors  of  the  Stomach:    Carcinoma — Sarcoma — Fibroma — Fibro- 

MYOMA — Lipoma — Adenoma — Papilloma — Polypi — Hernia 

Epigastrica 

Carcinoma — Heredity;  Situation;  Forms;  Comphcations;  Lactic 
Acid  as  a  Sign;  Results  of  Surgical  Treatment;  Internal  Treat- 
ment; Diet  Lists;  Lavage;  Radium;  Treatment  of  Carcinoma 
of  the  Cardia;  Sarcoma — Differential  Diagnosis;  Treatment; 
Benign  Tumors;  Hernia  Epigastrica 503-532 


f\.\'\'.)\  f 


DISEASES  OP  THE  STOMACH 


CHAPTER    I 

THE  PHYSIOLOGY  OF  DIGESTION 

The  physiology  of  digestion  appeals  to  the  physician, 
the  physiologist,  and  the  chemist,  from  sHghtly  varying 
viewpoints.  To  the  physiologist  and  the  chemist  the  pro- 
cess itself  is  the  chief  concern.  The  clinician  must  go 
farther:  he  must  not  only  be  conversant  with  the  changes 
which  take  place  under  normal  conditions,  but  he  must  be 
able  to  make  the  necessary  deductions  when  called  upon 
to  treat  abnormal  digestion.  While  the  physiologist  and 
the  chemist  study  the  stomach  or  the  action  of  the  gastric 
secretion,  the  physician  has  to  consider  this  organ  in  its 
relation  to  oral  and  intestinal  digestion  also. 

Digestion  proper  begins  with  the  mastication  and  insali- 
vation  of  food.  The  food  becomes  more  or  less  intimately 
incorporated  with  the  sahva  before  being  swallowed,  and, 
as  we  shall  see,  the  process  begun  in  the  mouth  continues 
in  the  stomach.  It  is  important  that  the  condition  of  the 
oral  and  buccal  cavity  should  be  the  best  possible.  Putre- 
factive processes  in  the  mouth  should  receive  prompt  atten- 
tion, and  the  dentist  should  be  consulted  at  regular  intervals. 

By  the  term  digestion  is  understood  the  process  of 
rendering  food  material  absorbable,  a  process  which  is  ac- 
comphshed  by  the  disintegrating  and  dissolving  action  of 
secretions  containing  enzymes,  assisted  to  a  greater  or  less 
extent  by  mechanical  action.  These  ferments  or  enzymes 
are  found  in  the  saliva,  gastric  juice,  bile,  and  pancreatic 
and  intestinal  juices.  Certain  fermentative  and  putrefactive 
agents  in  the  intestinal  canal  likewise  perform  an  important 
part  in  the  process  of  digestion. 
2 


18  THE  PHYSIOLOGY  OF  DIGESTION 


SALIVARY  DIGESTION 

Action  of  the  Saliva. — In  man  and  in  most  of  the  higher 
animals  the  sahva  has  a  twofold  action — physical  and 
chemical.  The  physical  action  of  sahva  consists  in  the 
moistening  of  the  food  so  as  to  facilitate  mastication  by 
the  teeth;  moreover,  by  virtue  of  the  mucin  it  contains,  all 
the  passages  become  lubricated,  rendering  more  easy  the  act 
of  deglutition  and  the  passage  of  the  bolus  of  food  into  the 
stomach.  In  dogs  the  physical  action  of  sahva  is  the  only 
one.  In  herbivorous  and  in  omnivorous  animals,  including 
man,  the  saliva  has  a  chemical  action  also,  which  is  very 
important  in  its  relation  to  the  digestion  of  starch.  Saliva 
has  a  specific  gravity  of  1.002.  '  The  secretion  from  the 
parotid  gland  contains  a  ferment,  ptyalin,  which  possesses 
the  property  of  converting  starch  into  dextrin  or  maltose. 
"WTiile  the  action  of  the  amylase,  ptyalin,  begins  with  the 
food  in  the  mouth,  the  greater  portion  of  salivary  digestion 
is  performed  during  the  first  period  of  digestion  in  the 
stomach;  for  though  the  partaking  of  food  causes  almost 
immediate  secretion  of  hydrochloric  acid  by  the  gastric 
glands,  some  time  must  elapse  (from  twenty  to  forty 
minutes)  before  the  acid  secretion  of  the  stomach  can  pene- 
trate the  food  sufficiently  to  inhibit  salivary  digestion. 
According  to  the  observations  of  Cannon  and  Griitzner,  the 
food  material  at  the  fundus  portion  of  the  stomach  may 
remain  undisturbed  for  a  considerable  time  and  thus  escape 
mixture  with  the  gastric  juice.  Complete  mastication  of 
food,  in  order  that  the  saliva  may  become  thoroughly 
incorporated  with  it,  is  imperative  for  complete  amylolysis. 

Ptyalin. — Ptyalin,  or  the  diastatic  ferment  of  the  saliva, 
converts  starches  as  well  as  glycogen  into  sugar.  This 
ferment  acts  in  a  slightly  alkahne  or  neutral  medium. 
Starches  are  first  converted  into  maltose  or  isomaltose, 
from  which  dextrose  appears  to  be  a  result  of  inversion  by 
maltase.  The  change  takes  place  to  better  advantage  in 
cooked  than  in  raw  starch.    The  several  intermediate  stages 


SALIVARY  DIGESTION  19 

in  the  transformation  of  starches  are  as  follows:  The  starch 
becomes  liquefied  so  as  to  form  a  true  solution,  rather  than 
a  suspension.  The  product  of  the  initial  stage  of  salivary 
digestion  is  known  as  amylodextrin,  ^Ji3~~turns  blue  when  cw-jX^ 
treated  with  a  dilute  LugoT^solifEibn.  As  the  process  con- 
tinues the  color  produced  by  the  Lugol  solution  grad- 
ually changes  from  a  blue  to  a  violet-red  and  finally  to  a 
mahogany  brown.  Starches  modified  to  this  extent  are 
known  as  ej;ythrodextrin.  As  the  process  of  salivary  diges- 
tion continues  still  further,  no  color  change  is  obtained  from 
the  addition  of  the  Lugol  solution;  the  term  achroodextrin 
is  used  to  designate  the  product  of  this  stage  of  the  diges- 
tive process.    These  changes  may  be  summarized  as  follows : 

1.  Amylodextrin  (soluble         Stains  blue  with  iodine  or  Lugol 

starches).  solution. 

2.  Erythrodextrin.  Lugol  solution  changes  first  to  a 

violet-blue,  then  red-violet,  and 
finally  mahogany  brown. 

3.  Achroodextrin.  No    color    change    produced    by 

Lugol  solution. 

4.  Maltose. 

5.  Dextrose. 

The  rapidity  of  the  diastatic  action  of  the  saliva  upon 
starches  is  checked  to  a  certain  extent  by  the  secretion  of 
hydrochloric  acid  after  the  food  arrives  in  the  stomach. 
According  to  the  researches  of  Van  den  Velden,  Ewald,  Boas, 
and  others,  the  action  of  the  ptyalin  is  limited  by  small 
quantities  of  acids,  while  larger  quantities  destroy  it  com- 
pletely. It  is  restricted  by  a  hydrochloric  acid  secretion  of 
0.07  per  cent.,  and  destroyed  entirely  by  0.12  per  cent.  Lactic 
acid,  0.1  per  cent.,  will  restrict  the  action  of  ptyalin,  and 
0.15  per  cent,  will  destroy  it  completely.  Boas  considers 
that  when  the  diastatic  ferment  of  the  sahva  has  not  been 
entirely  destroyed  by  a  high  degree  of  acidity  it  will  become 
again  active  in  the  stomach  upon  diminution  of  the  acid 
secretion  or  alkalization  of  the  stomach  contents.  He 
believes  that  ptyalin  digestion  is  not  confined  to  the  initial 
twenty  to  forty  minutes  during  which  the  food  in  the  stomach 
is  not  fairly  penetrated  by  the  hydrochloric  acid  secretion. 


20  THE  PHYSIOLOGY  OF  DIGESTION 


MOVEMENTS   OF   THE    STOMACH 

Solid  food  remains  in  the  stomach  for  several  hours, 
where  it  is  subjected  to  the  action  of  a  special  fluid,  the 
gastric  juice.  During  this  time,  b}^  muscular  contractions 
of  the  walls  of  the  stomach,  the  thinner  portions  of  the 
chymified  material  are  ejected  into  the  intestine.  The 
tonic  closure  of  the  sphincters  at  the  cardia  and  pj^lorus 
shuts  off  the  food  from  the  remainder  of  the  aUmentary 
canal  except  at  such  times  as  there  is  a  relaxation  of  the 
pylorus  to  permit  the  entrance  of  chj^me  into  the  duode- 
num. During  the  initial  stages  of  gastric  digestion  the  pylo- 
rus is  closed  so  firmly  that  upon  removal  of  the  stomach 
none  of  its  contents  will  escape.  As  digestion  advances, 
however,  the  pjdorus  offers  less  and  less  resistance,  until 
finally  it  yields  to  permit  the  passage  into  the  duodenum 
of  digested  gastric  contents. 

Since  the  discovery  of  the  .T-rays,  interesting  studies  have 
been  made  of  the  movements  of  the  stomach.  Cannon, 
among  others,  has  devoted  much  attention  to  the  subject. 
By  giving  an  animal  food  mixed  with  bismuth  subnitrate, 
he  was  able  to  obtain  skiagraphs  of  the  stomach,  the  bismuth 
being  opaque  to  the  .r-rays.  From  these  studies  it  has  been 
confirmed  that  peristaltic  movements  take  place  soon  after 
the  entrance  of  food  into  the  stomach.  According  to  Walter 
B.  Cannon,^  the  stomach  ''consists  of  two  parts  physiologic- 
ally distinct" — the  cardiac  portion,  a  food  reservoir  in  which 
saUvary  digestion  continues,  and  the  pyloric  portion,  the  seat 
of  active  gastric  digestion.  The  food  passes  from  the  former 
to  the  latter  by  tonic  contraction  of  the  muscles. 

According  to  Moritz,  Leven,  and  Cannon,  peristaltic  mus- 
cular activity  is  confined  to  the  pyloric  portion.  Tlio  last 
writer  holds  that  the  efficiency  of  peristalsis  in  mixing  the 
food  depends  upon  the  contraction  of  the  pyloric  sphincter, 
so  that  each  peristaltic  ring  or  contraction  wave  forces  the 

•  Medical  News,  May  20,  1905. 


MOVEMENTS  OF  THE  STOMACH  21 

gastric  contents  into  a  blind  pouch.  Unable  to  pass  out 
through  the  pyloric  exit,  the  food  is  forced  back  through  a 
succeeding  peristaltic  ring.  In  this  way  the  food  is  brought 
thoroughly  under  the  influence  of  the  glandular  secretions 
of  the  pyloric  portion  of  the  stomach.  According  to 
Moritz,  in  the  human  stomach  during  digestion  the  peri- 
staltic waves  occur  at  intervals  of  about  twenty  seconds. 
In  periods  of  relaxation  of  the  pyloric  sphincter,  as  diges- 
tion progresses,  these  contraction  waves  force  some  of  the 
fluid  contents  of  the  stomach  into  the  duodenum.  The 
hydrochloric  acid  secretion  in  the  stomach  apparently 
causes  the  pylorus  to  relax;  on  the  other  hand,  the  same 
acid  secretion  seems  to  have  the  opposite  effect  upon  the 
pylorus  after  the  acid  chyme  passes  into  the  duodenum, 
namely,  that  of  contraction.  After  the  propulsion  of  a 
certain  quantity  of  fluid  chyme  into  the  intestine  the  pylorus 
remains  closed  until  the  acid  on  the  distal  side  of  the  pyloric 
sphincter  becomes  neutralized  by  the  alkaline  pancreatic 
secretion  in  the  duodenum.  The  acid  chyme  provides  a 
chemical  stimulus  for  pancreatic  secretion. 

By  mixing  bismuth  subnitrate  with  the  food  and  obtain- 
ing a  skiagraph  of  the  stomach  during  the  process  of  diges- 
tion, it  has  been  learned  further  that  carbohydrate  foods 
begin  to  pass  out  of  the  stomach  a  comparatively  short 
time  after  ingestion,  requiring  only  about  one-half  as  much 
time  for  gastric  digestion  as  proteins.  When  taken  alone, 
fats  have  been  found  to  remain  for  a  long  time  in  the 
stomach,  and  when  taken  along  with  other  foods  they  delay 
to  a  marked  extent  the  passage  of  the  whole  chymified  food 
mass  into  the  intestine.  According  to  the  researches  of 
Cannon,  if  carbohydrates  be  fed  before  proteins  in  an  experi- 
mental diet,  the  former,  being  nearest  the  pyloric  portion 
of  the  stomach,  will  be  almost  immediately  propelled  into 
the  intestinal  canal,  leaving  the  protein  behind  to  be  acted 
upon  by  the  gastric  juice.  To  reverse  the  order  of  feeding 
will  retard  the  passage  of  carbohydrates  into  the  duodenum. 

The  stomach  is  essentially  an  automatic  organ.  Hof- 
meister  and  Schultz  have  shown  that  the  excised  stomach 


22  THE  PHYSIOLOGY  OF  DIGESTION 

when  kept  at  the  temperature  of  the  body  continues  to 
execute  regular  movements.  It  has  nerve  plexuses  within 
its  walls  and  is  also  connected  with  the  cerebrospinal  and 
sympathetic  systems.  During  digestion  the  normal  peri- 
staltic movements  of  the  stomach  are  in  all  probability  due 
to  a  local  reflex  from  Auerbach's  plexus.  Stimulation  of 
the  sympathetic  fibres  has  an  inhibitory  effect  upon  gastric 
peristalsis.  It  has  been  found  by  experiment  that,  as  a  rule, 
the  impulses  received  along  the  path  of  the  vagus  are  motor. 
The  automatic  rhythmical  contraction  is  inherent  in  the 
muscular  coat  of  the  stomach,  however,  and  is  merely  regu- 
lated by  impulses  from  the  central  nervous  system  passing 
down  the  vagi  or  splanchnic  nerves.  The  pyloric  sphincter 
as  well  as  the  remainder  of  the  musculature  of  the  stomach 
is  supplied  by  motor  fibres  from  the  vagus  nerve;  the 
splanchnic  nerves  constitute  the  source  of  inhibition.  Stim- 
ulation of  the  splanchnic  nerves  causes  the  contracted 
stomach  to  dilate  and  the  pylorus  to  relax. 


GASTRIC   DIGESTION 

We  are  indebted  to  Pawlow,  the  Russian  investigator,  for 
new  knowledge  concerning  the  physiology  of  digestion, 
especially  that  portion  of  the  subject  which  is  most  directly 
concerned  with  gastric  secretion.  Pawlow's  experiments 
enabled  him  to  study  the  gastric  secretion  in  dogs  after 
feeding  certain  foods,  and  the  effect  of  the  so-called  sham 
feeding  upon  gastric  secretion.  This  investigator  has  also 
studied  the  relation  between  the  action  of  gastric  and  that 
of  pancreatic  juice.  These  studies  were  facilitated  by  the 
establishment  of  a  gastric  fistula  leading  from  a  blind  pouch 
or  cul-de-sac.  We  have  learned  from  the  experiments  of 
Pawlow  that  the  glands  of  the  stomach  continue  to  secrete 
gastric  juice  until  the  food  enters  the  duodenum,  the  quantity 
of  secretion  being  in  proportion  to  the  quantity  of  food 
ingested.  While  the  secretion  of  the  stomach  under  normal 
conditions  is  always  acid,  the  acidity  increases  as  the  gastric 


GASTRIC  DIGESTION  23 

juice  is  more  rapidly  secreted.  Furthermore,  the  digestive 
power  of  the  gastric  juice  is  subject  to  variation,  depending 
upon  the  kind  of  food  ingested.  Gastric  juice  secreted  after 
a  bread  diet  is  said  to  possess  the  greatest  digestive  power, 
while  that  of  least  strength  follows  the  partaking  of  a  purely 
milk  diet.  The  total  acidity,  on  the  other  hand,  is  greatest 
after  meat  and  lowest  after  bread  diet.  From  the  point  of 
view  of  weight,  meat  requires  the  greatest  and  milk  the  smallest 
amount  of  gastric  juice.  In  the  majority  of  cases  the  so-called 
pyschic  secretion,  or  that  produced  by  the  sight,  taste,  or 
odor  of  food,  constitutes  the  commencement  of  gastric  secre- 
tion. Such  substances  as  meat  broths  and  meat  juices  or 
solutions  of  meat  extracts  are  excellent  stimulants  to  gastric 
secretion.  After  gastric  secretion  has  begun,  further  diges- 
tive power  is  developed  by  the  ingestion  of  bread  and  egg 
foods.  The  amalgamation  of  protein  and  starch  in  bread 
accounts  for  the  high  digestive  power  that  ''bread  juice" 
is  said  to  contain.  Fats  have  the  effect  of  diminishing  or 
inhibiting  secretion;  they  do  not  in  any  way  stimulate  it. 

Enzymes. — The  study  of  enzymes  has  engrossed  the  atten- 
tion of  a  number  of  observers  during  recent  years.  The 
commonly  accepted  view  of  the  mode  of  action  of  these 
ferments  is  that  originally  propounded  by  Osswald,  namely, 
that  they  act  by  catalysis.  The  term  is  employed  by  chem- 
ists to  designate  a  kind  of  reaction  which  is  brought  about 
by  the  mere  contact  or  presence  of  certain  substances 
known  as  catalyzers,  which  themselves  appear  to  remain  un- 
changed. As  defined  by  Starling,  a  catalyzer  is  a  substance 
which  will  increase  the  velocity  of  a  reaction  without  adding 
in  any  way  to  the  energy  changes  involved  in  the  reaction 
or  taking  part  in  the  formation  of  end  products.  The 
activity  of  enzymes  appears  to  be  specific  in  character; 
e.  g.,  those  ferments  which  act  upon  carbohydrates  are  not 
capable  of  producing  any  effect  upon  fats  or  proteins. 

The  enzymes  of  the  body  are  colloidal  in  structure,  with 
an  unknown  composition.  Most  of  them  are  soluble  in 
water,  glycerin,  or  physiologic  salt  solution.  They  are 
destroyed  completely  by  high  temperatures,  140°  to  175°, 


24  THE  PHYSIOLOGY  OF  DIGESTION 

and  their  physiologic  action  is  retarded  in  whole  or  in 
part  by  temperatures  only  slightly  below  the  normal. 
The  enzymes  are  capable  of  their  greatest  activity'  at  the 
temperature  of  the  human  body.  They  may  be  precipitated 
from  solution,  in  part  at  least,  by  alcohol,  which  property 
is  utiUzed  in  obtaining  purified  specimens.  Enzymes  may 
exist  in  an  inactive  or  latent  form  in  the  cells  which  pro- 
duce them,  and  may  be  still  inactive  after  they  are  secreted. 
The  inactive  or  latent  forms  of  enzymes  are  known  as  zymo- 
gens or  proenzymes.  Before  the  zymogen  can  become 
effectual,  it  requires  the  aid  of  some  other  agent.  The 
inorganic  substances  rendering  the  enzymes  active  agents 
in  digestion  are  known  as  activators;  organic  substances 
which  produce  the  same  result  are  called  kinases. 

The  fundus  and  the  pyloric  portion  of  the  stomach  are 
supplied  with  tubular  glands  which  exhibit  marked  differ- 
ences in  structure  in  the  two  parts.  In  man,  the  tubular 
glands  of  the  fundus  are  provided  with  a  duct  lined  with 
simple  columnar  epithelial  cells,  into  which  duct  empty  one 
or  two  secreting  tubules  supphed  -wdth  two  varieties  of  epi- 
thehal  cells,  namely,  central  or  peptic  cells,  and  parietal  or 
oxyntic  cells.  In  the  pyloric  portion  of  the  stomach  there 
is  only  the  one  kind  of  cell,  namely,  the  peptic.  The  pari- 
etal or  oxyntic  cells  are  the  acid-secreting  cells,  while  the 
central  or  peptic  cells  provide  the  pepsinogen  or  pepsin  and 
rennin  for  gastric  digestion. 

Pepsin. — Pepsin,  or  rather  pepsinogen,  is  active  only  in 
the  presence  of  free  hydrochloric  acid.  Hydrochloric  acid 
possesses  the  property  of  converting  pepsinogen  into  pepsin 
more  thoroughly  than  can  be  done  by  any  other  mineral 
acid.  Pepsinogen,  or  pepsin  in  the  latent  state,  has  such  a 
high  resistant  power  that  it  is  present  even  in  markedly 
advanced  stages  of  catarrhal  gastritis,  as  well  as  in  cancer. 
Peptones  constitute  the  end  result  of  peptic  digestion.  The 
conversion  of  proteins  and  gelatin  substances  into  soluble 
peptones  takes  place  by  degrees,  so  gradually  in  fact  that 
it  is  difficult  to  determine  the  intermediate  products  of  the 
process. 


GASTRIC  DIGESTION  25 

Hydrochloric  Acid. — Hydrochloric  acid  acts  in  various  ways 
in  performing  and  facilitating  the  normal  process  of  diges- 
tion. In  the  first  place,  it  is  antizymotic  and  antiseptic, 
destroying  pathogenic  microorganisms  and  arresting  fermen- 
tation; the  antiseptic  action  of  hydrochloric  acid  continues 
in  the  duodenum.  It  also  acts  as  a  means  of  regulating  peri- 
stalsis. Hydrochloric  acid  with  pepsin  converts  food  proteins 
into  peptones;  pepsin,  however,  is  the  chief  agent  in  this 
transformation  process,  hydrochloric  acid  acting  as  an  adju- 
vant. By  hydrochloric  acid  cane  sugar  is  converted  into 
dextrose  and  levulose. 

Normal  Gastric  Juice. — Normal  gastric  juice  is  a  thin, 
colorless  or  nearly  colorless  fluid,  with  a  strongly  acid 
reaction  and  a  characteristic  odor;  its  specific  gravity  is 
about  1.002.  The  acidity  of  the  gastric  juice  is  due  to  the 
presence  of  free  hydrochloric  acid,  the  amount  of  which 
varies  according  to  the  duration  of  digestion.  The  acidity 
at  the  beginning  of  digestion  is  low,  owing  to  the  fact  that 
a  portion  of  the  acid  is  neutrahzed  by  the  alkalinity  of 
the  sahva  incorporated  with  the  food.  While  the  gastric 
juice  has  a  more  or  less  constant  acidity,  its  reaction  may 
be  diminished  by  alkalies  in  the  stomach,  or  by  combination 
with  the  protein  of  the  food,  forming  acid-albumins  or 
syntonins.  The  normal  acidity  of  the  gastric  juice  of  man, 
estimated  to  be  0.2  per  cent.,  may,  according  to  Hornberg, 
reach  0.4  or  0.5  per  cent,  during  digestion. 

Pawlow,  in  his  work  on  the  digestive  glands,  has  demon- 
strated that  gastric  secretion  is  under  the  control  of  the 
nervous  system,  and  that  the  secretory  fibres  are  contained 
in  the  vagus.  If  the  vagus  be  cut  below  the  origin  of  the 
recurrent  laryngeal,  so  as  to  avoid  paralysis  of  the  larynx, 
and  sham  feeding  performed,  there  is  no  gastric  secretion, 
proving  conclusively  that  the  vagus  contains  the  secretory 
fibres.  The  hypothesis  is  confirmed  by  stimulation  of  the 
peripheral  end  of  the  cut  nerve.  Pawlow's  experiment, 
which  consists  in  dividing  the  esophagus  of  a  dog  in  the 
neck,  and  connecting  the  esophageal  mucous  membrane 
with   the   skin  so  as  to  form  a  fistulous   opening,  is  well 


26  THE  PHYSIOLOGY  OF  DIGESTION 

known.  Food  fed  to  Pawlow's  dogs  escaped  through  the 
fistulous  opening  in  the  esophagus  without  reaching  the 
stomach.  The  sham  meal,  as  the  experimenter  designates 
it,  had  the  effect  of  producing  a  copious  flow  of  gastric 
juice,  so  long  as  the  vagus  nerve  was  intact.  The  flow  of 
gastric  juice  resulted  evidently  from  a  stimulation  of  the 
secretory  fibres  of  the  vagus  nerve,  by  the  sensations  of 
sight,  odor,  taste,  etc.,  during  the  masticating  and  swallow- 
ing of  food.  The  beginning  of  gastric  secretion,  according 
to  Pawlow,  is  psychic. 

Under  normal  conditions  gastric  juice  continues  to  be 
secreted  so  long  as  food  remains  in  the  stomach.  Pawlow 
has  taught  that  mechanical  stimulation  of  the  gastric  mu- 
cous membrane  has  no  effect  upon  the  secretion  of  the  glands 
of  the  stomach.  The  sensation  of  eating  serves  to  start 
the  secretion  in  an  ordinary  meal.  The  afferent  stimuli 
originate  in  the  mouth  and  nostrils  and,  as  stated,  probably 
with  the  sense  of  sight.  The  efferent  path  is  through  the 
vagus  nerve.  In  this  way  begins  gastric  digestion,  the 
further  action  of  which  is  conditioned  by  the  stomach  itself 
and  its  contents.  Some  food  articles,  among  which  are  meat 
extracts,  meat  juices,  and  soups,  and  in  a  less  degree  milk 
and  water,  are  said  to  contain  substances  which,  when  taken 
into  the  stomach,  promote  gastric  secretion. 

"Secretin." — Decoctions  of  the  mucous  membrane  of  the 
pylorus  injected  into  the  blood  are  found  to  increase  the 
secretion  of  gastric  juice.  According  to  Edkins,  secretagogues 
pre-formed  in  the  food  or  produced  during  digestion  act 
upon  the  mucous  membrane  of  the  pylorus,  giving  rise  to 
a  "gastrin,"  or  gastric  "secretin,"  which,  after  absorption 
into  the  blood,  is  carried  to  the  gastric  glands  and  stinui- 
lates  them  to  secretion.  These  chemical  messengers  deter- 
mining the  various  secretions,  such  as  gastric,  pancreatic, 
hepatic,  and  intestinal,  have  been  designated  horfnoncs 
(from  oiiif/Ko.  I  arouse  or  excite)  (Starling). 

Pepsin. — Pepsin  is  a  proteolytic  ferment  capable  of  act- 
ing only  in  an  acid  medium,  so  that  peptic  digestion  in  the 
stomach  is  a  result  of  the  combined  action  of  pepsin  and 


GASTRIC  DIGESTION  27 

hydrochloric  acid.  Pepsin,  as  stated,  is  formed  in  the  central 
or  peptic  cells  of  the  gastric  mucosa;  it  is  present  in  the 
cells  as  a  zymogen  or  pepsinogen,  which  does  not  becojne 
active  pepsin  until  after  it  is  secreted.  Pepsinogen  is 
quickly  converted  into  active  pepsin  by  the  action  of  the 
hydrochloric  acid  of  the  gastric  secretion.  Owing  to  the 
constant  presence  of  hydrochloric  acid  in  normal  gastric 
secretion,  pepsin  is  always  present  in  active  form. 

The  principal  action  of  the  gastric  juice  consists  in  the 
conversion  of  the  proteins  of  the  food  into  diffusible  pep- 
tones. Soluble  protein,  after  passing  through  several  inter- 
mediate stages,  the  results  of  which  have  been  isolated  and 
named  acid-albumin,  parapeptone,  and  propeptone,  be- 
comes peptone.  The  first  step  in  the  digestion  of  protein 
consists  in  its  conversion  into  an  acid-albumin  (syntonin). 
Under  the  action  of  pepsin,  syntonin  or  acid-albumin  under- 
goes hydrolysis,  producing  protalbumoses.  Under  the  con- 
tinued influence  of  pepsin  these  bodies  undergo  further 
hydrolysis,  with  the  consequent  formation  of  secondary 
proteoses  (deutero-albumoses).  The  further  hydrolysis  of 
the  secondary  proteoses  results  in  the  production  of  pep- 
tones. 

Rennin. — Rennin  is  analogous  to  pepsin  in  that  it  is 
formed  in  the  principal  or  central  cells  and  is  present  in 
the  cells  as  a  zymogen.  The  conversion  of  prorennin  into 
the  active  enzyme  takes  place  very  readily  under  the  influ- 
ence of  hydrochloric  acid.  Rennin  possesses  the  property 
of  curdling  the  casein  of  milk,  to  which  its  action  in  the 
stomach  appears  to  be  entirely  confined.  Casein,  the  chief 
protein  in  milk,  has  an  important  nutritive  value.  It  is 
digested,  like  other  proteins,  by  pepsin  in  the  stomach  and 
trypsin  in  the  intestine,  the  end  result  of  the  process  of 
gastric  digestion  being  peptone. 

Lipase. — It  has  been  demonstrated  by  Volhard  that  the 
normal  gastriemucosa  in  man  secretes  a  lipase,  or  fat-sphtting 
ferment,  which  acts  readily  upon  the  emulsified  fats  of 
milk,  cream,  or  yolk  of  egg.  This  ferment,  which  is  secreted 
by   the   cells    of    the   fundus   of    the   stomach,    has    been 


28  THE  PHYSIOLOGY  OF  DIGESTION 

extracted  by  means  of  glycerin.  It  is  inactive  in  an  alkaline 
medium. 

Fats  in  gastric  digestion  become  liquefied  by  the  heat  of 
the  body,  and,  being  thus  set  free  from  their  intimate  admix- 
ture with  other  foodstuffs,  are  disseminated  throughout  the 
chyme  by  the  movements  of  the  stomach.  In  this  way  they 
are  prepared  for  digestion  by  the  pancreatic  juice  and  bile 
in  the  intestine. 

Absorptive  Power  of  the  Stomach. — It  is  probable  that  the 
absorptive  power  of  the  stomach  is  limited  to  such  sub- 
stances as  salts,  sugars,  and  dextrins  that  may  have  been 
formed  from  starch  in  salivary  digestion.  Absorption  does 
not  take  place  readily  in  the  stomach;  it  is  a  distinctive 
feature  of  intestinal  digestion.  According  to  von  ]\Iering, 
water  when  taken  alone  is  practically  not  at  all  absorbed 
in  the  stomach,  but  as  soon  as  introduced  begins  to  pass 
into  the  intestine  in  a  series  of  spurts,  by  the  contraction 
of  the  walls  of  the  stomach.  Von  Mering  has  also  demon- 
strated that,  while  the  stomach  is  capable  of  absorbing  carbon 
dioxide,  alcohol,  sugar,  dextrin,  or  peptones,  in  solution,  it 
can  absorb  little  or  no  water.  On  the  other  hand,  when 
the  foregoing  substances,  except  water,  are  taken  into  the 
stomach,  water  is  secreted  b.y  the  gastric  glands  in  propor- 
tion to  the  amount  of  the  substances  absorbed. 


INTESTINAL  DIGESTION 

Pancreatic  secretion  is  stimulated  to  its  greatest  activity 
by  the  presence  of  such  acids  as  hydrochloric,  phosphoric, 
citric,  lactic,  or  acetic,  which  seem  to  be  equally  effective  in 
this  regard.  Condiments  have  little  or  no  effect  upon  it. 
It  has  been  found  impossible  to  stimulate  pancreatic  secre- 
tion by  way  of  the  rectum;  the  one  efficient  stimulus  is 
contingent  upon  the  outpouring  of  acid  chyme  into  the 
duodenum.  Pancreatic  secretion  is  increased  by  tlie  pres- 
ence of  fat,  which  also  causes  an  increase  in  the  lipogenic 
ferment.     Water  is  also  a  stimulant  to  pancreatic  secretion. 


INTESTINAL  DIGESTION  29 

When  the  Hquefied  food  in  the  form  of  chyme  passes 
through  the  pylorus  it  is  subjected  to  the  digestive  action  of 
the  bile  and  the  pancreatic  and  intestinal  juices.  While  the 
greatest  quantity  of  gastric  secretion  occurs  the  first  hour 
after  a  meal,  the  maximum  of  pancreatic  secretion  occurs 
about  the  third  hour,  at  a  time  coincident  with  the  presence 
of  the  greatest  amount  of  chyme  in  the  duodenum.  The 
cells  of  the  intestinal  mucosa  produce  a  prosecretin,  an 
inactive  substance  which  is  converted  into  secretin  when 
the  acid  chyme  enters  the  duodenum.  Secretin  is  a  hormone 
which  acts  upon  the  pancreas  through  the  circulation.  The 
secretion  of  pancreatic  juice  seems  to  take  place  automatic- 
ally :  when  the  acid  chyme  becomes  neutralized  by  the  alka- 
line secretion  of  the  pancreas,  the  formation  of  secretin  is 
inhibited  until  the  entrance  of  a  further  quantity  of  acid 
chyme,  when  secretin  is  again  produced  and  taken  up  by 
the  circulation,  whence  it  again  excites  the  flow  of  pan- 
creatic juice.  The  pancreatic  secretion  contains  three 
ferments— namely,  amylopsin,  by  which  starch  is  converted 
into  dextrin  and  maltose  and  later  into  glucose;  lipase,  a 
ferment  which  possesses  the  property  of  acting  upon  neutral 
fats,  converting  them  into  fatty  acids  and  glycerin;  and 
trypsinogen,  a  latent  enzyme,  which  is  transformed  into 
an  active  enzyme  by  the  ferment  enterokinase  found  in 
the  intestinal  juice.  The  intestinal  juice  contains  secretin, 
enterokinase,  and  a  proteolytic  enzyme  described  by  Cohn- 
heim  and  named  by  him  erepsin.  Erepsin,  while  not 
capable  of  acting  upon  original  protein,  acts  on  albu- 
moses  and  peptones,  which  it  splits  into  simpler  molecules 
(amino-acids) ,  apparently  completing  the  work  of  the  pepsin 
and  trypsin.  In  addition  to  these,  the  intestinal  juice  con- 
tains three  enzymes  which  act  upon  carbohydrates.  They 
are:  maltase,  which  acts  on  maltose;  invertin,  which  acts  on 
cane  sugar;  and  lactase,  which  acts  on  ixdlk  sugar. 

Bile  possesses  weak  amylolytic  fermentative  action.  Its 
most  important  function  is  to  assist  in  the  digestion  and 
absorption  of  fats.    It  is  probable  that  in  the  digestion  and 


30  THE  PHYSIOLOGY  OF  DIGESTION 

absorption  of  fats  the  action  of  both  pancreatic  juice  and 
bile  is  essential. 

Intestinal  digestion  takes  place  in  the  upper  portion  of 
the  small  intestine.  The  function  of  the  lower  segments 
of  the  small  intestine,  as  well  as  the  colon,  is  absorption  of 
fluids.  The  colon  possesses  the  further  function  of  acting  as 
a  reservoir  or  container  for  food  residues. 


CHAPTER    II 

EXAMINATION   OF  THE   STOMACH  CONTENTS 

Examination  of  material  obtained  from  the  fasting 
stomach  is  one  of  the  most  important  diagnostic  aids  in 
ascertaining  the  nature  and  extent  of  pathologic  conditions 
of  the  stomach. 

The  presence  of  food  remnants  in  large  quantities  from 
the  last  or  from  a  preceding  meal,  especially  if  sour- 
smelUng,  points  to  a  disturbance  of  gastric  motility.  If 
the  quantity  of  gastric  juice  which  may  be  removed 
from  the  fasting  stomach  constantly  exceeds  100  Cc,  a 
condition  known  as  gastrosuccorrhea  (Reichmann's  disease), 
gastrorrhea,  hypersecretion,  or  gastrochylorrhea,  is  present. 
According  to  recent  investigations,  it  is  highly  probable 
that  gastrochylorrhea  is  a  sequel  to  disturbance  of  the 
motor  functions  of  the  stomach.  A  small  amount  of  mucus 
and  saliva  may  be  found  in  the  normal  fasting  stomach, 
its  viscidity  being  observed  in  pouring  from  one  vessel  to 
another.  Numerous  mucin  bodies  and  epithelial  cells  are 
seen  upon  microscopic  examination.  The  presence  of  mucus 
and  saliva  in  the  fasting  stomach  may  be  due  to  stomatitis, 
pharyngitis,  ptyalism,  or  pathologic  conditions  affecting  the 
glandular  portion  of  the  stomach. 

Bile  may  regurgitate  into  the  stomach  from  the  duo- 
denum. When  it  has  been  long  in  the  stomach  it  under- 
goes change,  its  biUrubin  becoming  biliverdin,  so  that  the 
fluid  takes  on  a  yellowish  or  greenish  color.  According 
to  Brucke,  bile  does  not  interfere  with  the  peptic  activity 
of  the  gastric  glands,  except  that,  like  every  albuminoid 
body,  it  has  a  strong  affinity  for  the  acid  of  the  stomach. 
Sometimes  in  the  fasting  stomach  a  mixture  of  bile,  pan- 
creatic juice,  and  perhaps  succus  entericus  is  found.    Intes- 


32  EXAMINATION  OF  THE  STOMACH  CONTENTS 

tinal  juices  in  small  quantities  have  no  special  pathologic 
significance. 

Blood  is  found  in  the  stomach  under  such  conditions  as 
hemorrhage  from  gastric  ulcer,  irritation  of  the  pathologic 
gastric  mucosa  upon  the  passing  of  a  stomach  tube,  and 
vigorous  movements  caused  by  expression  of  stomach  con- 
tents. Hemorrhages  may  originate  in  the  esophagus, 
pharynx,  nasal  cavity,  or  lungs.  Hemoptysis  and  hematem- 
esis  may  exist  contemporaneously;  when,  however,  they  are 
not  found  together,  it  is  not  a  difficult  matter  to  distin- 
guish the  source  in  cases  of  either  kind  of  hemorrhage. 
Slight  hemorrhages,  when  there  is  an  admixture  of  blood 
and  mucus,  are  significant  only  when  found  upon  repeated 
examinations. 

Pus,  according  to  recent  investigators,  is  frequently 
found  in  stomach  contents.  Boas  has  found  it  in  cases  of 
ulcerating  carcinoma.  It  is  easily  recognized,  even  macro- 
scopically,  in  such  cases,  by  the  foul-smelling  yellowish-green 
and  occasionally  blood-stained  masses. 


TEST   MEALS 

The  normal  secretion  of  the  gastric  juice  has  been  thor- 
oughly studied  in  man  by  Ewald  and  Boas.  They  find 
that  the  secretion  of  gastric  juice  starts  almost  as  soon 
as  the  food  enters  the  stomach  and  continues  until  it 
enters  the  duodenum.  The  investigations  of  Pawlow  show 
that  the  secretion  of  gastric  juice  starts  even  before  the 
food  reaches  the  stomach  (psychic  secretion).  During  the 
latter  part  of  digestion  in  the  stomach  the  secretion  of 
gastric  juice  normally  decreases,  for  which  reason  the  results 
of  analytic  examination  of  the  gastric  contents  are  sub- 
ject to  variation.  The  first  hydrochloric  acid  secreted  by 
the  stomach  unites  with  all  the  protein  and  salts  to  form 
combined  acids.  Only  after  all  these  affinities  have  been 
satisfied  can  we  find  free  hydrochloric  acid.  If  a  meal 
consists  of  large  quantities  of  protein,  it  is  obvious  that  free 


TEST  MEALS  33 

hydrochloric  acid  will  appear  later  than  if  the  meal  con- 
sisted in  larger  proportion  of  carbohydrates.  A  test  meal 
should  contain  all  the  ingredients  of  an  ordinary  meal. 
In  order  to  make  a  study  of  the  secretory  function  of  the 
stomach,  it  is  necessary  to  have  some  one  meal  taken  as  a 
standard.  For  this  reason  test  meals  of  known  compo- 
sition are  given  for  analytic  purposes.  It  is  customary  to 
give  test  meals  in  the  morning,  w^hen  the  stomach  is  most 
likely  to  be  empty;  occasionally,  however,  the  test  meal  is 
given  at  noon  or  in  the  evening,  depending  upon  the  pur- 
pose in  view. 

Ewald-Boas  Test  Breakfast. — Ewald-Boas'  test  breakfast  con- 
sists of  a  roll  or  two  slices  of  white  bread  without  butter 
and  two  small  cups  (300  to  400  Cc.)  of  water  or  weak  tea 
without  cream  or  sugar.  The  patient  should  thoroughly 
masticate  the  bread  or  roll.  The  stomach  contents  should 
be  removed  in  one  hour,  since  digestion  is  at  its  height  at 
this  time.  This  test  breakfast  contains  protein,  sugar, 
starches,  non-nitrogenous  extractives,  and  salts.  It  will  thus 
be  seen  that  the  stomach  is  offered  all  the  usual  ingredients 
of  a  meal,  with  the  advantage  that  the  whole  is  liquefied 
in  a  very  short  time  and  so  modified  that  passage  of  the 
contents  through  the  stomach  tube  is  not  hindered,  as 
might  be  the  case  if  more  solid  food  were  taken.  This  test 
breakfast,  while  suitable  for  routine  examination,  has  the 
disadvantage  of  introducing  into  the  stomach  a  variable 
amount  of  lactic  acid  as  well  as  numerous  yeast  cells  with 
the  bread. 

Boas'  test  breakfast  consists  of  a  tablespoonful  of  rolled  oats 
in  a  quart  of  water,  reduced  to  one  pint  by  boiling.  A  pinch 
of  salt  is  added  to  make  it  more  palatable  to  the  patient. 
This  meal,  inasmuch  as  it  does  not  contain  lactic  acid,  is 
usually  given  when  detection  of  lactic  acid  is  important, 
as  in  cases  of  suspected  cancer. 

Riegel  Test  Dinner. — At  noon  the  patient  is  given  a  meal 

consisting  of  beef  broth,  150  to  200  grammes  of  beefsteak, 

50  grammes  potatoes  as  puree,  and  a  roll  of  white  bread.    The 

stomach  contents  are  removed  in  from  three  to  four  hours 

3 


34  EXAMINATION  OF  THE  STOMACH  CONTENTS 

and  examined.  The  advantage  of  this  test  meal  is  the 
opportunity  it  affords  to  note  the  degree  of  digestibility 
of  starches  and  proteins.     Fleiner's  test  meal  is  similar. 


MACROSCOPIC   EXAMINATION    OF    STOMACH   CONTENTS 

Having  withdrawn  the  test  meal  at  the  allotted  time,  the 
physician  should  carefully  inspect  the  appearance  and  note 
the  quantity  and  odor  of  the  material.  After  the  stomach 
tube  is  introduced,  as  stated  on  page  123,  there  are  two 
methods  of  obtaining  the  stomach  contents:  (1)  The  ex- 
pression method  of  Ewald  and  Boas,  and  (2)  aspiration  by 
means  of  some  suction  apparatus. 

Methods  for  Obtaining  Stomach  Contents. — Expression  Method. 
— The  first  method  is  the  simplest  and  easiest  at  our 
command,  and  the  stomach  tube  itself  is  the  only  instru- 
ment necessary.  The  tube  being  in  the  stomach,  the  patient 
is  instructed  to  take  a  deep  inspiration,  to  hold  his  breath, 
and  bear  down  with  his  abdominal  muscles,  when  the  gas- 
tric contents  will  pour  out  from  the  end  of  the  tube  into  a 
tumbler  held  for  their  reception.  Sometimes  coughing  or 
moving  the  tube  a  little  will  produce  a  gagging  sensation, 
and  this  induces  the  abdominal  pressure  that  forces  out  the 
stomach  contents.  Should  nothing  come  through  the  tube, 
it  may  be  assumed  that  the  stomach  is  empty.  In  removing 
the  tube  it  is  well  to  cover  the  end  snugly  with  the  finger, 
to  prevent  the  escape  of  so  much  of  the  stomach  contents  as 
the  tube  contains,  thereby  adding  so  much  more  to  the  quan- 
tity for  examination  and  at  the  same  time  avoiding  a  ''muss." 

Aspiration  Method. — For  removing  gastric  contents  by 
the  second  method,  almost  any  instrument  that  will  create 
a  vacuum  may  be  employed.  The  so-called  "stomach 
pump  "  has  been  used,  but  it  has  been  found  that  sometimes, 
even  in  its  careful  use,  pieces  of  gastric  mucous  membrane 
are  detached — drawn  into  the  eye  of  the  tube.  The 
aspirator  bulb  of  Ewald  seems  to  be  now  in  general  use. 
It  is  really  a  ten-ounce  Politzer  bag,  provided  at  its  upper 


MACROSCOPIC  EXAMIXATIOX  OF  STOMACH  CONTEXTS      35 

end  with  a  large-sized  hard  rubber  tip,  over  which  the  stom- 
ach tube  can  be  adjusted  (Fig.  1).    The  air  is  forced  out  of 


Fig.  1 


Fig.  2 


Stomach  tube  and  aspirator. 


Stomach  bucket. 


36  EXAMINATION  OF  THE  STOMACH  CONTENTS 

the  bag,  which  is  then  attached  to  the  stomach  tube  while 
the  latter  is  in  the  stomach.  By  allomng  the  bag  to  expand, 
the  stomach  contents  are  aspirated.  Aspirating  bottles 
with  stopcocks  and  other  complicated  attachments  have 
been  devised  for  the  removing  of  the  stomach  contents, 
but  such  apparatus  is  really  unnecessary.  Einhorn^  has 
devised  a  stomach  bucket  to  remove  the  stomach  contents. 
It  consists  of  a  small  capsule-shaped  vessel  (Fig.  2)  made 
of  silver  (If  cm.  long,  |  cm.  wide),  open  at  the  top  and  for 
a  short  distance  down  the  side.  The  opening  is  surmounted 
by  an  arch,  to  which  a  silk  thread  is  tied,  and  a  knot  made 
sixteen  inches  from  the  attachment.  In  order  to  secure  a 
sample  of  the  stomach  contents,  the  bucket  is  first  dipped  in 
lukewarm  water  (filled  and  emptied)  to  facilitate  filling  when 
in  the  stomach;  the  patient  is  asked  to  open  his  mouth  wide, 
and  the  bucket  is  placed  on  the  root  of  the  tongue  (almost 
in  the  pharynx) ;  the  patient  is  then  instructed  to  perform 
the  act  of  swallowing,  and  within  one  or  two  minutes  the 
bucket  enters  the  stomach.  It  is  left  there  for  five  minutes 
,and  then  withdrawn.  During  the  withdrawal  of  the  appa- 
ratus, resistance  is  usually  felt  at  the  introitus  esophagi. 
To  overcome  this  difficulty  the  patient  is  again  instructed 
to  swallow,  by  which  act  the  larynx  is  pushed  forward  and 
upward  so  as  to  free  the  passage,  when  the  bucket  can  be 
easily  withdrawn.  If  the  stomach  was  not  empty,  the  bucket 
returns  with  gastric  contents  sufficient  for  the  making  of 
various  important  tests. 

Inspection  of  Stomach  Contents. — By  inspection  one  should 
distinguish  between  absolutely  undigested,  partially  digested, 
and  well  digested  contents.  It  is  also  possible  to  distin- 
guish by  inspection  between  carbohydrate  and  protein 
digestion.  Absolutely  undigested  food  masses  are  found 
in  advanced  cases  of  gastric  catarrh,  in  atrophic  con- 
ditions of  the  gastric  mucous  membrane,  and  likewise  in 
achylia  gastrica.  The  presence  of  undigested  food  points 
also  to  marked  secretory  disturbance.  In  such  conditions 
the  appearance  of  the  test  meal  after  removal  resembles 

*  Diseeises  of  the  Sfomach,  1906,  p.  81. 


MACROSCOPIC  EXAMINATION  OF  STOMACH  CONTENTS     37 

that  of  a  mixture  of  the  bread  and  water  before  ingestion. 
The  absence  of  peptic  digestion  is  ascertained  by  the  clear- 
ness of  the  filtrate.  By  inspection  the  presence  of  blood, 
mucus,  bile,  or  intestinal  juices,  and  occasionally  pus,  animal 
parasites,  and  fragments  from  the  gastric  mucosa,  may  be 
detected.  In  cases  characterized  by  marked  gastric  reten- 
tion, the  stomach  contents  when  placed  in  a  vessel  are  some- 
times observed  to  be  in  three  separate  layers.  The  upper 
consists  of  mucus,  or  undigested  food  particles  which  have 
undergone  fermentation;  the  next,  which  is  the  largest,  of 
fluid ;  while  that  on  the  bottom  of  the  vessel  consists  of  chyme. 
This  is  the  condition  found  in  abnormal  gastric  fermentation 
and  extreme  gastric  insufficiency. 

According  to  Boas,  the  filtrate  of  the  entire  contents  of 
the  normal  stomach,  evacuated  exactly  one  hour  after  a 
test  breakfast,  measures  20  to  50  Cc.  There  may  be  much 
less  than  this,  or  the  stomach  may  be  entirely  empty;  if  so, 
the  condition  is  what  has  been  designated  hypermotility  or 
hyperkinesis,  found  in  organic  and  nervous  gastric  affec- 
tions, such  as  chronic  gastritis,  achyha  gastrica,  buhmia, 
and  whenever  there  is  insufficiency  of  the  pylorus.  On  the 
other  hand,  if  remnants  of  the  preceding  meal  are  con- 
stantly found  in  the  stomach  contents  in  the  morning,  the 
finding  is  indicative  of  impairment  in  gastric  motihty,  the 
degree  of  which  can  be  ascertained  only  by  repeated  exami- 
nations of  the  stomach  contents. 

Determination  of  Gastric  Juice. — The  method  of  Mathieu 
and  Remond  is  commonly  used  to  determine  the  total 
amount  of  gastric  juice  secreted.  The  gastric  contents  are 
removed  as  completely  as  possible  at  the  stated  interval 
after  an  Ewald  test  breakfast.  Water,  200  cubic  centi- 
meters, is  then  poured  into  the  stomach  through  the  stomach 
tube  and  thoroughly  mixed  with  the  gastric  contents  by 
moving  the  funnel  up  and  down,  as  well  as  by  pressure  upon 
the  stomach.  As  much  as  possible  of  this  fluid  is  collected 
in  a  separate  receptacle,  and  the  chnician  proceeds  to  ascer- 
tain the  acidity  of  the  undiluted  as  well  as  that  of  the 
diluted  stomach  contents.     From  these  data,  conclusions 


38  EXAMIXATIOX  OF  THE  STOMACH  CONTEXTS 

may  be  drawn  as  to  the  degree  of  dilution  and  the  amount 
of  the  residual  gastric  contents. 

Mathieu  endeavors  to  ascertain  the  total  stomach  con- 
tents by  the  following  formula: 

a  =  the  acidity  of  the  undiluted  gastric  contents. 
6=the  acidity  of  the  diluted  gastric  contents. 

a;=the  amount  of  the  test  meal  remaining  in  the  stomach  after  the  first 
extraction. 
200  C.c.=the  amount  of  water  introduced  into  the  stomach  for  dilution. 

Then 

a  -.b  :  :  {x  +  200) :  x 
ax  =  bix  +  200) 
200  & 

^  =  — »: 

a — 0 

In  ascertaining  the  acidity  of  the  stomach  contents,  it  is 
necessary  to  determine  the  total  available  acidity  rather 
than  the  mere  degree  of  acidity. 

Color. — Gastric  juice  is  a  colorless  hquid,  though  at  times 
it  may  show  a  mild  opacity.  It  may  vary,  however,  with 
the  color  of  food  taken.  Coffee  or  particles  of  toasted 
bread  will  lend  a  distinctly  brownish  coloration,  while  meat 
will  tend  to  discolor  the  juice  red.  A  distinct  red  color 
may  also  be  due  to  the  presence  of  blood,  which  grows 
darker  the  longer  the  blood  remains  in  the  stomach.  The 
color  of  gastric  contents  may  be  either  yellow  or  green, 
due  to  the  presence  of  bihrubin  or  biliverdin,  bihary 
pigments  which  may  be  detected  by  the  tests  for  bile  in 
the  urine.  A  brownish-black  coloration  and  fetid  odor 
of  the  stomach  contents  points  to  intestinal  obstruction 
below  the  duodenum. 

Odor. — The  odor  of  normal  gastric  juice  is  sHghtly  sour. 
It  is  offensive  when  the  gastric  juice  is  mixed  with  materials 
from  the  intestinal  canal.  In  the  vomitus  of  uremia  there 
is  often  a  distinct  odor  of  ammonia;  an  alcoholic  odor  is 
present  in  alcoholic  intoxication.  Stagnation  of  gastric 
contents  gives  rise  to  an  intensely  strong  odor. 

Consistency. — Usually  watery  in  character,  the  normal 
stomach  contents  vary  with  the  character  of  the  extraneous 
material  composing  them.    In  catarrhal  gastritis  or  in  cases 


CHEMIC  EXAMINATION  OF  STOMACH  CONTENTS 


39 


marked  by  subacidity,  there  may  be  present  after  a  test 
meal  so  much  tough,  shmy  mucoid  material  as  to  render 
filtering  of  the  stomach  contents  impossible. 

The  stomach  is  practically  never  empty,  always  contain- 
ing a  certain  quantity  of  fluid,  acid  in  reaction,  which  Boas 
regards  as  normal  in  amounts  of  not  less  than  ten  or  more 
than  a  hundred  cubic  centimeters.  Riegel,  on  the  other 
hand,  regards  any  amount  of  material  in  the  fasting  stomach 
as  pathologic. 

CHEMIC  EXAMINATION  OF  STOMACH  CONTENTS 

Chemic  examination  of  gastric  contents  consists  in  the 
use  of  reagents  to  determine  the  actual  state  of  digestion, 
so  that  by  comparing  it  with  normal  physiologic  digestion 
one  may  obtain  information  in  regard  to  any  functional  dis- 
turbances or  changes  present.     These  examinations  should 


Fig.  3 


Necessary  apparatus  for  making  analysis  of  stomach  contents:  a,  glass  tumbler  for  holding 
stomach  contents;  6,  filter  paper;  c,  glass  funnel;  d,  sedimentation  glass;  e,  gastric  filtrate; 
/,  graduated  pipets,  holding  5  Cc;  g,  porcelain  spoon;  h,  beaker;  i,  alcohol  lamp;  j,  buret 
for   titrating  with  xa  normal  sodium  hydrate  solution;   k,  buret  stand. 


be  made  as  frequently  as  may  be  necessary  to  enable  the 
clinician  to  form  a  correct  estimate  of  the  condition  of  the 
gastric  function;  it  is  only  in  rare  cases  that  positive  results 
can  be  obtained  from  a  single  examination. 

Apparatus. — The  special  apparatus  required  for  the  analytic 
work  is  very  simple  (Fig.  3). 


40  EXAMINATION  OF   THE  STOMACH  CONTENTS 

In  a  complete  chemic  analysis  the  following  tests  should 
be  made: 

Test.  Reagents. 

1.  Reaction Litmus. 

2.  Hydrochloric  acid Glinzburg. 

3.  Total  acidity Phenolphthalein.  . 

4.  Free  hydrochloric  acid       ....  Dimethylamidoazobenzol. 

5.  Combined  hydrochloric  acid  .      .      .  Ahzarin. 

6.  Lactic  acid Uffelmann. 

7.  Pepsin Mett. 

8.  Rennin  Calcium  chloride. 

9.  Propeptone Copper  sulphate. 

10.  Peptone Sodium  chloride. 

11.  Dextrin Lugol  solution. 

12.  Erythrodextrin Lugol  solution. 

13.  Achroodextrin Lugol  solution. 

14.  Maltose Fehling  solution. 

Determination  of  Reaction. — After  the  macroscopic  examina- 
tion of  the  stomach  contents,  a  portion  should  be  filtered 
and  the  filtrate  tested  by  litmus  paper,  in  order  to  ascertain 
the  reaction,  which  may  be  acid,  alkaline,  amphoteric,  or 
neutral.  If  the  reaction  is  found  to  be  acid,  the  next 
step  is  to  ascertain  the  presence  of  free  hydrochloric  acid. 
This  is  done  by  means  of  Congo  red.  Congo  red  was  intro- 
duced into  practice  and  recommended  in  the  form  of  Congo 
paper,  as  a  reagent  for  free  hydrochloric  acid.  Congo  red 
in  solution  is,  however,  more  sensitive  than  Congo  paper. 
The  solution  is  prepared  by  dissolving  one  gramme  of  the 
powdered  Congo  in  100  Cc.  of  water.  By  the  use  of  the 
solution  0.0009  per  cent,  of  hydrochloric  acid  may  be 
detected,  while  the  paper  does  not  react  unless  0.01  per 
cent,  of  hydrochloric  acid  is  present.  Congo  red  paper 
consists  simply  of  filter  paper  saturated  with  an  alcoholic 
solution  of  Congo  red  and  permitted  to  dry.  The  presence 
of  free  hydrochloric  acid  in  the  gastric  juice  is  determined 
by  the  changing  of  the  Congo  red  to  blue  on  contact  with 
the  stomach  contents.  The  test  confirms  the  presence  of 
free  mineral  acids  only.  It  has  been  found  that  gastric  juice 
will  sometimes  react  distinctly  because  of  the  presence  of 
either  free  lactic  or  free  acetic  acid.    The  test  may  be  used, 


CHEMIC  EXAMINATION  OF  STOMACH  CONTENTS         41 

however,  for  the  detection  of  free  hydrochloric  acid,  since 
this  is  ordinarily  the  only  mineral  acid  to  be  found  in  the 
stomach  contents. 

Dimethylamidoazobenzol  Test. — This  test  depends  upon  the 
coloration  which  a  0.5-per-cent.  alcoholic  solution  of 
dimethylamidoazobenzol  produces  when  treated  with  gastric 
juice  containing  free  hydrochloric  acid.  To  make  the  test, 
a  few  cubic  centimeters  of  filtered  gastric  juice  are  placed 
in  a  porcelain  spoon  or  dish,  and  one  to  two  drops  of  the 
dimethylamidoazobenzol  solution  added.  A  carmine  red 
color  results  when  free  hydrochloric  acid  is  present.  This 
reagent  does  not  react  to  organic  acids  unless  they  are 
present  in  amount  over  0.5  per  cent.  The  proportion  of  free 
hydrochloric  acid  present  may  be  determined  by  the  inten- 
sity of  coloration  when  the  reagent  is  added,  for  so  small  a 
proportion  as  one  part  to  fifty  thousand,  or  0.02  per  thousand, 
gives  the  color  reaction.  From  a  clinical  point  of  view 
it  is  of  the  utmost  importance  to  determine  the  presence 
or  absence  of  hydrochloric  acid.  After  this  has  been  deter- 
mined, then  it  must  be  ascertained  whether  the  secretion 
is  increased  or  decreased.  When  free  hydrochloric  acid  is 
found  to  be  present,  it  is  unnecessary  to  test  for  pepsin  or 
pepsinogen,  since  these  ferments  are  always  present  when  free 
hydrochloric  acid  can  be  demonstrated,  \^^len,  however,  this 
acid  is  absent,  we  may  still  have  a  secretion  of  pepsinogen. 

For  the  detection  of  free  hydrochloric  acid  the  Giinzburg 
test  is  perhaps  the  most  reliable. 

Giinzburg's  Test. — Giinzburg's,  or  the  phloroglucin-vanillin, 
reagent  is  prepared  as  follows: 

Gm.  or  Cc. 

I^ — Phloroglucini         2.0         3ss 

Vanillini 1.0        gr.  xv 

Alcoholis  absoluti 30.0        oj 

Misce. 

Three  drops  of  filtered  stomach  contents  are  placed  in  a 
porcelain  spoon  or  dish  (Fig.  3,  g);  to  this,  3  drops  of  the  rea- 
gent are  added  from  a  small  pipet,  and  the  two  solutions  are 
thoroughly  mixed.  The  porcelain  spoon  or  dish  is  then  very 
carefully  heated  over  a  small  flame  (Fig.  3,  i),  when  if  free 


42  EXAMINATION  OF  THE  STOMACH  CONTENTS 

hydrochloric  acid  is  present  a  cherry  red  tint  is  obtained 
around  the  edges  of  the  mixture  (Plate  I,  Figs.  3  and  4). 
This  color  is  due  to  the  deposition  of  very  fine  crystals,  an 
effect  which  would  occur  in  even  aqueous  solutions  of  0.01 
per  cent.  This  peculiar  color  is  not  produced  by  any  organic 
acid  whatsoever.  Instead  of  the  phloroglucin  solution,  a 
filter  paper  prepared  by  means  of  it  is  sometimes  used; 
when  moistened  with  two  or  three  drops  of  stomach  con- 
tents and  heated,  it  reveals  the  presence  of  hydrochloric  acid 
by  developing  the  same  cherry  red  tint.  The  test  with  the 
solution  is  more  reUable. 


QUANTITATIVE   ANALYSIS 

The  buret  is  used  for  all  quantitative  analyses.  It  is 
graduated  into  tenths  of  a  cubic  centimeter  so  as  to  be 
easily  read.  The  buret  should  be  fixed  in  a  perpendicular 
position  and  firmly  attached  to  its  stand.  It  should  be 
filled  through  a  glass  funnel  with  the  solution  to  be  used. 
Care  must  be  exercised  to  avoid  the  presence  of  air  bubbles. 
The  buret  is  graduated  from  zero  to  30  Cc.  Allow  enough 
of  the  solution  to  run  out  to  remove  the  bubbles  and  to 
bring  the  solution  down  to  the  zero  mark.  In  reading  off 
the  quantity  of  solution  that  has  been  used,  great  care 
should  be  taken  to  read  at  the  level  of  the  bottom  of  the 
meniscus  formed  by  the  attraction  of  the  fluid  to  the  cyUn- 
drical  wall  of  the  buret. 

Normal  Solutions. — For  the  quantitative  analysis  of  the 
acid  in  the  gastric  contents,  normal  solutions  are  used.  A 
normal  solution  of  acid  or  alkah  is  one  in  which  each  Hter 
represents  the  amount  in  grammes  of  reagent  found  by 
dividing  the  molecular  weight  of  the  substance  by  the 
number  of  replaceable  hydrogen  atoms  or  hydroxyl  groups. 
A  decinormal  solution  is  one-tenth  the  strength  of  the 
normal  solution.  It  is  this  latter  that  is  used  in  mak- 
ing stomach  analyses.  In  the  various  tests  employed  in 
quantitative  analysis  for  acidity  of  the  gastric  contents, 
one-tenth  normal  sodium  hydrate  is  used  in  the  buret.    The 


PLATE  I 


FIG.   2 


^■ 


Pheiiolphthalein  Test. 

Before  adding  2*'- sodium   hydrate 
solution. 


Phenolphthalein  Test. 

After  rendering  alkaline  with  -If, 
sodium   hydrate  solution. 


'IG.   8 


Gunzburg  Test  (Faint  Reaction). 


FIG.    4 


Gunzburg  Test  (Marked   Reaction). 


quantitative:  analysis  43 

amount  of  this  alkali  necessary  to  neutralize  a  given  quan- 
tity of  the  acid  in  the  gastric  juice  will  give  the  degree  of 
acidity.  It  has  been  found  that  the  normal  acidity  of  the 
stomach  contents  at  the  height  of  digestion  (one  hour  after 
a  test  breakfast)  will  range  between  40  and  60  degrees, 
which  means  the  number  of  cubic  centimeters  of  one-tenth 
normal  sodium  hydrate  solution  necessary  to  neutralize 
100  Cc.  of  gastric  juice.  For  example,  if  we  use  2.5  Cc.  of 
one-tenth  normal  sodium  hydrate  solution  to  neutralize  5  Cc. 
of  gastric  juice,  the  degree  of  acidity  would  be  2.5  X  20 
=  50).  We  multiply  by  20  because  we  always  figure  on  the 
amount  necessary  to  neutralize  100  Cc.  of  gastric  juice,  and 
since  we  have  used  only  5  Cc.  for  the  test,  we  must  multiply 
by  20  to  bring  this  up  to  100. 

One  cubic  centimeter  of  one-tenth  normal  sodium  hydrate 
solution  will  neutrahze  0.00365  gramme  of  free  hydrochloric 
acid.  If  now  w^e  multiply  this  factor  by  the  number  of 
cubic  centimeters  necessary  to  neutralize  100  Cc.  of  the 
filtered  gastric  juice  (degree  of  acidity),  the  result  will  be 
the  percentage  of  acid  present.  If  the  normal  acidity  is 
between  40  and  60  degrees,  the  percentage  will  be  found 
by  multiplying  by  0.00365. 

Minimum  normal  acidity  40  degrees,  0.00365   X  40   =   0.146  per  cent. 
Maximum  normal  acidity  60  degrees,  0.00365    X  60   =   0.219  per  cent. 

After  an  Ewald-Boas  test  breakfast  an  excess  of  free 
hydrochloric  acid  should  be  present  within  fifty  or  sixty 
minutes,  while  after  a  Riegel  test  dinner  it  is  present  in 
from  two  and  a  half  to  three  hours. 

The  elements  to  which  the  acid  reaction  of  stomach  con- 
tents is  attributable  are  outlined,  according  to  Boas,  in  the 
following  table: 

1.  Hydrochloric  acid 

free  combined 

(with  proteins,  basic  substances) 

2.  Organic  acids  (lactic,  butyric,  acetic  acids) 

free  combined 

(with  proteins,  basic  substances 

3.  Acid  phosphates. 


44  EXAMINATION  OF  THE  STOMACH  CONTENTS 

Since  the  normal  acidity  of  the  stomach  contents  is  between 
40  and  60  degrees,  cHnicians  have  for  the  most  part  agreed 
that  above  60  degrees  shall  constitute  hyperchlorhydria, 
hyperacidity,  or  superacidity;  below  40  degrees,  hypochlor- 
hydria,  hypoacidity,  or  subacidity;  absence  of  acid,  achlor- 
hydria,  anacidity,  or  achylia.  The  total  acidity  is  ascertained 
by  the  phenolphthalein  test. 

Phenolphthalein  Test. — The  total  acidity  is  determined  with 
one-tenth  normal  sodium  hydrate  solution  in  the  buret. 
The  indicator  consists  of  a  1-per-cent.  alcoholic  solution  of 
phenolphthalein.  Draw  into  a  graduated  pipet  10  Cc.  of 
the  filtered  gastric  juice  (Fig.  3,  /).  Pour  the  contents  of  the 
pipet  into  a  beaker  (Fig.  3,  h).  To  this,  add  three  or  four 
drops  of  the  phenolphthalein  solution,  which  will  cause  a 
grayish  clouding  (Plate  I,  Fig.  1).  The  one-tenth  normal 
sodium  hydrate  solution  is  gradually  added  until  red  is 
discerned  at  the  point  where  the  solution  from  the  buret 
touches  the  gastric  juice.  By  agitation,  the  red  color  dis- 
appears. Add  more  of  the  sodium  hydrate  solution  and 
again  agitate  the  contents  of  the  beaker.  When  the  reddish 
color  ceases  to  disappear,  a  sufficient  quantity  of  the  one- 
tenth  normal  sodium  hydrate  solution  has  been  added  to 
neutralize  the  total  acidity  of  the  stomach  contents.  Care 
must  be  taken  not  to  add  too  much.  The  end  of  the  test 
shows  a  slight  red  (Plate  I,  Fig.  2).  It  is  now  necessary  to 
read  on  the  buret  the  amount  used.  If  we  have  used  4.5  Cc. 
we  multiply  by  10,  because  we  calculate  the  amount  neces- 
sary to  neutrahze  100  Cc,  and  we  find  that  our  acidity  is 

45  degrees.     The  percentage  is  ascertained  by  multiplying 
the  45  by  0.00365,  making  0.16425  per  cent. 

It  is  very  important  to  make  a  quantitative  estimate 
of  free  hydrochloric  acid  in  studying  all  pathologic  con- 
ditions of  the  stomach.  When,  however,  the  amount  of 
free  hydrochloric  acid  is  diminished,  it  is  necessary  to  exer- 
cise caution  in  the  interpretation  of  either  qualitative  or 
quantitative  tests  for  free  hydrochloric  acid.  In  compara- 
tively rare  cases  all  the  indicators,  with  the  exce])tion  of 
Giinzburg's   reagent,   have  given   a   positive  reaction    for 


PI   ATF    \] 


Topfer  Test. 

Dimethylamidoazobenzol  as  in- 
dicator, before  adding  ^,  sodium 
liydrate  solution. 


Topfer  Test. 

DimethylanTiidoazobenzor  as  in- 
dicator, after  rendering  alkaline 
with  ,^  sodium    hydrate  .solution 


Topfer  Test. 

Alizarin   as    indicator,   before 
adding    ^   sodium       hydrate 


solution. 


Topfer  Test. 

Alizarin    as    indicator,    aftev 
rendering    alkaline    wi; 
.sodium   hydrate  solutic' 


QUANTITATIVE  ANALYSIS  45 

hydrochloric  acid  when  no  hydrochloric  acid  was  actually 
present. 

Mintz's  Method. — To  10  Cc.  of  gastric  juice  add  20  to  30 
drops  of  Giinzburg's  reagent  as  indicator.  The  solution  is 
then  warmed,  and  decinormal  sodium  hydrate  solution 
added.  Since  the  reaction  takes  place  only  when  the 
solution  is  warm,  the  glass  rod  with  which  the  solution  is 
stirred  should  be  warmed  before  using.  A  distinct  red  color 
will  be  evident  along  the  sides  of  the  rod  as  the  point  of 
neutraUzation  is  reached. 

Topfer's  Method. — Topfer's  method  of  quantitative  analy- 
sis of  gastric  juice  is  the  simplest  and  most  delicate 
of  tests  for  free  hydrochloric  acid.  One-half  per  cent, 
dimethylamidoazobenzol  alcohohc  solution  is  used  as  an 
indicator.  The  titration  of  the  filtered  gastric  juice  is  done 
with  decinormal  sodium  hydrate  solution.  Lactic  acid  will 
not  respond  to  the  test  unless  it  be  present  to  the  extent 
of  1  per  cent.,  which  is  rarely  the  case.  Acetic  and  butyric 
acids  are  present  in  fairly  large  amounts  in  fermentative 
processes  of  the  stomach;  when  present  in  sufficient  quanti- 
ties to  interfere  with  the  reaction  for  hydrochloric  acid, 
their  strong  odor  renders  them  easy  of  detection.  To  10  Cc. 
of  the  filtered  gastric  juice,  one  or  two  drops  of  indicator  are 
added;  if  hydrochloric  acid  is  present,  a  bright  red  tone  results 
(Plate  II,  Fig.  1),  so  the  mere  presence  or  absence  of  hydro- 
chloric acid  is  easily  determined.  The  quantitative  deter- 
mination is  now  made  by  adding  decinormal  sodium  hj'drate 
solution;  as  this  solution  is  added,  the  reddish  tint  of  the 
mixture  changes  to  a  distinct  yellow.  The  titration  must 
proceed  to  the  point  at  wh^ch  all  trace  of  red  disappears 
and  the  color  becomes  clear  yellow  (Plate  II,  Fig.  2).  To 
ascertain  the  amount  of  free  hydrochloric  acid  present,  note 
the  number  of  cubic  centimeters  of  decinormal  sodium 
hydrate  solution  used  from  the  buret.  Multiply  this  by 
10,  in  order  to  determine  the  amount  necessary  to'neutraUze 
100  Cc.  of  gastric  juice — the  figures  also  representing  the 
degree  of  free  hydrochloric  acid  present.  Multiplying  this 
result  by  0.00365  we  get  the  percentage  of  hydrochloric  acid. 


46  EXAMINATION  OF  THE  STOMACH  CONTENTS 

In  making  these  tests  the  physician  should  always  work 
with  filtered  gastric  contents,  since  otherwise,  owing  to  the 
presence  of  food  particles,  an  exact  measurement  of  the 
quantity  of  gastric  juice  can  seldom  be  made. 

Combined  Hydrochloric  Acid. — Since  the  hydrochloric  acid  at 
first  secreted  combines  with  basic  substances  and  the  protein 
of  the  ingested  food,  if  we  would  know  the  total  amount  of 
hj^drochloric  acid  secreted  we  must  ascertain  just  how  much 
acid  salts  and  acid  protein  has  been  formed  in  the  stomach. 
The  physiologically  active  hydrochloric  acid  consists  of  both 
free  and  combined  acid.  There  may  be  only  a  small  amount 
of  free  hydrochloric  acid,  while  that  combined  with  the  pro- 
tein may  be  comparatively  large.  Sometimes  there  is  no 
free  hydrochloric  acid,  but  a  large  quantity  of  combined  acid, 
showing  that  a  certain  amount  has  been  secreted  by  the 
stomach. 

Among  the  methods  of  determining  the  quantity  of  com- 
bined acid  is  that  of  Topfer.  The  total  acidity  of  the 
gastric  juice  is  determined  by  titration  of  10  Cc.  of  filtered 
gastric  juice  with  decinormal  sodium  hydrate  solution, 
using  phenolphthalein  as  an  indicator,  as  described  on  page 
44.  This  point  having  been  determined,  a  second  portion 
of  10  Cc.  of  gastric  juice  is  titrated  with  decinormal  sodium 
hydrate  solution,  using  a  1-per-cent.  aqueous  solution  of 
alizarin  as  an  indicator  (alizarin  monosulphate  of  sodium). 
Two  or  three  drops  of  this  indicator  are  added  to  10  Cc.  of 
filtered  gastric  juice,  when  the  mixture  becomes  distinctly 
yellow  (Plate  II,  Fig.  3).  The  titration  is  carried  on  to 
the  point  of  production  of  a  pure  violet  color  (Plate  II, 
Fig.  4),  which  does  not  deepen  on  the  further  addition  of 
an  alkali.  Alizarin  reacts  with  free  acid,  both  mineral 
and  organic,  and  with  free  acid  salts,  but  not  with  com- 
bined hydrochloric  acid.  If,  therefore,  we  subtract  the  figure 
obtained  when  alizarin  is  used  as  an  indicator  from  that 
obtained  with  phenolphthalein,  the  result  will  be  combined 
hydrochloric  acid.  For  example:  Suppose  that  by  the  use 
of  phenolphthalein  and  decinormal  sodium  hydrate  solution 
all  the  acidities  have  been  saturated,  the  color  being  red, 


PLATE   in 


FIG.    1 


V. 


UffeliTiaiin's  Test. 

Fig.  1:     Before  adding  gastric   filtrate  containing  lactic  acid. 
Fig.  2:    After  adding   gastric   filtrate  containing  lactic  acid. 


QUANTITATIVE  ANALYSIS  47 

and  the  result  is  60  degrees;  then  by  the  use  of  alizarin  and 
decinormal  sodium  hydrate  solution  all  the  acidity  excepting 
the  combined  hydrochloric  acid  is  neutralized,  the  color  being 
violet,  and  the  result  is  38  degrees.  By  subtracting  the  acidity 
found  with  alizarin  (38)  from  the  acidit}^  found  with  phe- 
nolphthalein  (60)  the  amount  of  combined  hydrochloric  acid 
is  determined:  60  -  38  =  22,  and  22  X  0.00365  =  0.0803  per 
cent.  If  we  now  add  this  combined  hydrochloric  acid  to 
the  free  hydrochloric  acid  determined  by  titration  of  the 
gastric  juice,  using  dimethylamidoazobenzol  as  an  indi- 
cator, we  obtain  the  total  physiologically  active  hydro- 
chloric acid.  The  difference  between  the  total  acidity  and 
this  factor  gives  us  the  amount  of  organic  acid  and  acid 
salts  present. 

Lactic  Acid. — Since  bread,  milk,  and  meat  contain  lactic 
acid,  any  test  for  lactic  acid  can  be  of  value  only  when  the 
meal  contains  very  little  of  these  foods.  The  Boas  test 
meal  is  preferable  when  the  object  is  to  detect  the  presence 
of  lactic  acid.  According  to  Boas,  under  physiologic 
conditions  no  appreciable  amount  of  lactic  acid  is  formed 
during  digestion.  Lactic  acid  is  apt  to  be  found  in  any 
condition  associated  with  stagnation  of  the  gastric  contents 
as  a  result  of  motor  insufficiency,  provided  the  amount 
of  hydrochloric  acid  is  below  normal.  An  excess  of  lactic 
acid  would  suggest  gastric  cancer,  though  it  should  not  be 
overlooked  that  an  excess  of  lactic  acid  may  be  present 
in  benign  stenosis  of  the  pylorus  and  motor  insufficiency. 
Should  the  stomach  be  washed  out  the  evening  before  the 
test  meal,  and  lactic  acid  appear  in  the  stomach  contents 
after  the  night's  fast,  the  pathologic  condition  is  probably 
cancer.  Where  carcinoma  has  developed  from  the  base  of 
an  old  ulcer,  the  findings  may  show  no  lactic  acid,  but,  on 
the  contrary,  large  amounts  of  hydrochloric  acid. 

Uffelmann's  Test. — Uffelmann's  reagent  consists  of  10  Cc.  of 
a  4-per-cent.  carbolic  acid  solution  to  which  are  added  one 
drop  of  ferric  chloride  solution  U.  S.  P.  and  sufficient  water 
to  form  a  transparent  amethyst  blue  (Plate  III,  Fig.  1).  A 
solution  should  be  freshly  prepared  for  each  test.     Add  a 


48 


EXAMINATION  OF  THE  STOMACH  CONTENTS 


Fig.  4 


■25C.C. 


few  drops  of  filtered  gastric  juice  to  5  Cc.  of  this  reagent 
in  a  test-tube,  and  in  the  presence  of  lactic  acid  the  solution 
will  lose  its  blue  color  and  take  on  a  beautiful  canary  yellow 
or  greenish-yellow  tint  (Plate  III,  Fig.  2).     Should  there  be 

considerable  hydrochloric  acid 
present  in  the  gastric  juice  the 
result  may  be  obscured.  The 
stomach  contents  under  this  con- 
dition should  be  extracted  with 
ether,  which  takes  up  the  lactic 
acid,  leaving  the  other  substances 
behind.  The  ethereal  solution  is 
then  evaporated,  the  residue  taken 
up  with  distilled  water,  and  the 
Uffelmann  test  applied  to  this 
solution;  if  lactic  acid  is  present, 
the  solution  turns  intensely  green. 
Strauss'  Test. — A  clinical  test  that 
has  been  used  with  success  is  that 
recommended  by  Strauss.  He  has 
devised  a  glass  funnel  (Fig.  4) 
which  makes  the  test  quite  simple. 
The  funnel  is  graduated  to  5  Cc. 
below  and  25  Cc.  above.  It  is 
filled  to  the  5-Cc.  mark  with 
filtered  gastric  juice,  and  ether  is 
added  to  the  25-Cc.  mark.  The 
funnel  is  corked  and  thoroughly 
shaken.  After  standing  for  a 
short  time  to  allow  the  fluids  to 
separate,  the  contents  are  allowed 
to  run  out  through  the  stopcock 
to  the  5-Cc.  mark.  Distilled 
water  is  added  up  to  the  25-Cc.  mark,  and  then  two  drops  of 
tincture  of  iron  chloride.  On  shaking  the  mixture,  if  an 
appreciable  quantity  of  lactic  acid  is  present  an  intense  green 
color  results;  a  pale  green  indicates  a  trace  of  lactic  acid. 


-5c.c. 


Strauss'  funnel  for  making  lactic 
acid  test. 


EXAMINATION  OF  ENZYMES  49 


EXAMINATION   OF  ENZYMES 


Pepsinogen  and  Pepsin. — Through  the  action  of  acids,  and 
especially  hydrochloric  acid,  pepsinogen  is  converted  into 
active  pepsin,  which  is  able  to  convert  proteins  into  a  form 
in  which  they  may  be  assimilated.  If  the  gastric  contents 
contain  free  acids  and  digested  proteins,  pepsin  is  present. 
If  there  are  no  free  acids,  but  the  digestive  power  be- 
comes apparent  when  the  material  is  treated  with  sufficient 
hydrochloric  acid,  pepsin  is  demonstrated.  To  ascertain  the 
presence  of  pepsin  when  free  hydrochloric  acid  is  present, 
10  Cc.  of  gastric  contents  are  placed  in  a  test-tube,  a  little 
disk  of  coagulated  egg  albumin  added,  and  the  test-tube 
placed  in  an  incubator,  which  is  kept  at  a  constant  temper- 
ature between  98°  and  100°  F.;  disappearance  of  the  egg 
albumin  after  a  short  interval  points  to  the  presence  of  pepsin. 

When  hydrochloric  acid  is  absent,  pepsinogen  alone  may 
be  found  in  the  stomach  contents.  This  is  important  to  the 
diagnostician,  inasmuch  as  pepsinogen  is  rarely  absent.  The 
absence  of  pepsinogen  means  atrophy  or  achylia.  In  the 
absence  of  hydrochloric  acid,  pepsinogen  is  practically  inert. 
Whenever  pepsinogen  is  found,  it  is  wise  to  prescribe  hydro- 
chloric acid,  thus  making  use  of  the  digestive  ferment  natu- 
rally present.  Hydrochloric  acid  transforms  pepsinogen  into 
pepsin  in  less  than  a  minute.  The  test  for  pepsinogen  is 
made  by  adding  to  10  Cc.  of  filtered  gastric  juice  one  or 
two  drops  of  hydrochloric  acid  and  proceeding  as  with  the 
qualitative  test  for  pepsin. 

Determination  of  Pepsin. — Ricin  Test. — Jacoby-Solrns  Method. 
— One  gramme  of  ricin  is  dissolved  in  100  Cc.  of  a  5-per- 
cent, solution  of  sodium  chloride,  and  the  whole  filtered. 
Two  cubic  centimeters  of  the  filtrate  are  mixed  with  0.5 
Cc.  of  a  decinormal  HCl  solution,  1  Cc.  of  diluted  stom- 
ach contents  is  added,  and  the  mixture  is  maintained  at 
body  temperature  for  three  hours.  Ferments  clear  up  the 
ricin  deposit.  The  quantity  of  pepsin  is  determined  from 
the  degree  of  dilution  in  which  the  stomach  contents  will 
4 


50  EXAMINATION  OF  THE  STOMACH  CONTENTS 

cause  the  ricin  deposit  to  disappear.  Solms  considers  one 
pepsin  unit  the  amount  of  gastric  juice  which  is  sufficient  to 
clear  up  2  Cc.  of  a  2-per-cent.  ricin  solution  in  three  hours  at 
blood  temperature.  Normal  stomach  contents  contain  about 
100  pepsin  units  to  the  cubic  centimeter.  As  a  means  of 
maintaining  uniform  temperature,  Einhorn  employs  an  ordi- 
nary thermos  bottle  with  a  device  to  hold  the  tubes,  which 
are  graduated  in  millimeters.  The  thermos  bottle  should  be 
partly  filled  with  water  at  a  temperature  of  100''  F.  The 
tubes  in  which  the  tests  are  being  made  should  be  tightly 
corked. 

Mett  Test. — A  capillary  glass  tube  is  used,  into  which  fresh 
egg  albumin  is  drawn  by  suction.  The  contents  of  the  tube 
are  coagulated  by  immersion  for  five  minutes  in  boiling 
water.  By  cutting  the  tube  into  pieces  2  to  5  centimeters 
long  the  pieces  can  easily  be  placed  in  a  beaker  containing 
the  gastric  juice  to  be  tested.  They  should  then  be  kept 
in  an  incubator  for  ten  hours  at  a  temperature  of  95°  to 
98°  F.  At  the  end  of  this  time  the  albumin  will  be  seen  to 
have  disappeared  from  the  ends  of  each  piece,  while  there 
still  remains  some  in  the  central  portion  of  each.  The 
empty  ends  are  measured.  The  square  of  the  length  of  the 
column  of  albumin  digested  is  the  measure  of  the  amount 
of  pepsin  in  the  gastric  juice.  For  instance,  if  the  empty 
portion  of  the  tube  be  3  millimeters  in  length  the  digestion 
equals  3  X  3  or  9  parts  of  pepsin.  The  peptic  unit  is  that 
quantity  of  pepsin  which  will  digest  one  millimeter  of  egg 
albumin  in  a  Mett  tube  in  ten  hours,  the  tubes  being  im- 
mersed in  0.18-per-cent.  free  hydrochloric  acid. 

Qualitative  Test  foi*  Rennin. — Five  to  ten  cubic  centi- 
meters of  filtered  stomach  contents  are  accurately  neutral- 
ized with  decinormal  sodium  hydrate  solution.  The  same 
quantity  of  neutral  or  ainphotoric  boiled  milk  is  added  and 
the  mixture  placed  in  an  incubator.  If  the  curdHng  j)ro- 
cess  begins  within  fifteen  minutes  and  a  coaguluni  is  formed 
when  the  mixture  is  further  allowed  to  stand,  the  phenom- 
enon of  coagulation  is  attributable  to  the  action  of  rennin. 
Leo's  test  for  rennin  is  substantially  as  follows:    Add  three 


EXAMINATION  OF  ENZYMES  51 

to  five  drops  of  gastric  contents  to  five  to  ten  cubic  centi- 
meters of  milk,  and  place  in  an  incubator;  if  coagulation 
follows  in  ten  to  fifteen  minutes,  lab-ferment  is  present. 

To  test  for  rennin  zymogen,  add  three  to  five  drops  of  a 
1-per-cent.  calcium  chloride  solution  to  10  Cc.  of  milk  to 
which  three  to  four  drops  of  gastric  filtrate  have  been  added, 
and  place  in  an  incubator.  If  coagulation  of  casein  occurs 
in  the  course  of  a  few  minutes,  rennin  zymogen  is  present. 

According  to  Boas,  a  pronounced  diminution  of  the  spe- 
cific biologic  action  of  ferments  is  directly  indicative  of 
disturbance  of  the  function  of  the  glandular  apparatus  of 
the  stomach  itself.  By  examination  of  the  gastric  enzymes 
it  may  be  determined  in  individual  cases  whether  impair- 
ment of  the  glandular  apparatus  is  transitory  or  permanent. 
Hydrochloric  acid  secretion  is  sometimes  temporarily  inhib- 
ited in  anomalies  of  menstruation,  in  nervous  dyspepsia,  in 
congested  conditions,  and  in  acute  and  the  early  stages  of 
chronic  gastritis.  In  these  conditions  the  presence  or  absence 
of  enzymes  indicates  whether  the  physician  has  to  deal  with 
only  a  temporary  suppression  of  the  hydrochloric  acid  secre- 
tion or  with  an  advanced  or  chronic  gastric  catarrh. 

Test  for  Propeptone. — The  end  products  of  protein  diges- 
tion in  the  stomach  are  to  be  found  in  propeptones  and 
peptones.  The  amino-acids  are  all  formed  in  the  intestine. 
To  test  for  propeptone,  mix  equal  parts  of  the  filtered  stom- 
ach contents  and  a  saturated  solution  of  sodium  chloride. 
A  turbid  precipitation  indicates  the  presence  of  propep- 
tones. When  there  is  no  precipitation,  but  the  addition  of 
two  or  three  drops  of  acetic  acid  turns  the  liquid  turbid, 
propeptone  is  present.  When  the  solution  is  heated  the  tur- 
bidity clears  up,  and  when  it  cools  the  turbidity  returns.  The 
more  turbid  the  solution,  other  things  being  equal,  the  greater 
the  amount  of  propeptone  present. 

Test  for  Peptone. — After  having  filtered  out  the  propeptone, 
5  Cc.  of  the  filtrate  is  made  strongly  alkaline  by  adding 
sodium  hydrate  solution.  A  few  drops  of  a  1-per-cent. 
sulphate  of  copper  solution  are  added.  \^Tien  peptone  is 
present  a  purple  or  violet-red  color  (biuret  reaction)  appears. 


52  EXAMINATION  OF  THE  STOMACH  CONTEXTS 


CARBOHYDRATE   DIGESTION  IN   THE   STOMACH 

The  conversion  of  starches  into  sugar  occupies  three  inter- 
mediary stages,  which  are  determined  by  their  behavior 
toward  Lugol  solution.  The  stages  are  amiduUn,  erythro- 
dextrin,  and  achroodextrin.  With  Lugol  solution,  amiduUn 
gives  a  blue  color,  erythro dextrin  a  violet  or  mahogany 
brown,  achroodextrin  remains  unchanged.  The  end  prod- 
uct of  the  conversion  of  starch  into  sugar  is  maltose 
(C12H22O11  +  H2O),  together  with  small  amounts  of  dextrose, 
which  may  be  demonstrated  by  Fehling's  or  Xylander's 
tests.  Lugol  solution  consists  of  pure  iodine,  1  gramme; 
potassium  iodide,  2  grammes;  distilled  water,  enough  to 
make  20  cubic  centimeters. 

In  hj-perchlorhydria  the  digestion  of  starch  has  been 
found  to  be  considerabh^  impaii^ed;  in  testing  the  stomach 
contents  for  starch,  iodine  gives  a  pronounced  blue  coloring. 
In  achlorhydria  the  reaction  is  \\'ine-yellow.  The  first  result 
is  more  likely  to  be  obtained  when  there  is  an  impairment 
of  the  saHvary  glands  whereby  the  secretion  becomes  poor 
in  ptyalin.  In  am^  case  where  hyperacidity  is  present  sali- 
vary digestion  stops  as  soon  as  the  food  enters  the  stomach; 
in  subacid  conditions  salivary  digestion  may  proceed  indefi- 
nitely in  the  stomach,  depending,  of  course,  upon  the  extent 
of  the  diminution  of  gastric  secretion. 


BLOOD  IN   GASTRIC   CONTENTS 

The  presence  of  blood  in  gastric  contents  must  be  con- 
sidered always  pathologic;  it  is  most  frequently  associated 
wdth  erosion,  gastric  ulcer,  and  gastric  carcinoma.  In 
gastric  ulcer  the  blood  is  usually  bright  red  in  appearance, 
unless  changed  by  the  action  of  the  acid  of  the  gastric 
juice,  in  which  case  it  takes  on  a  brownish  discoloration. 
In  hemorrhages  resulting  from  gastric  cancer  the  blood  is 
more  thoroughly  incorporated  with  the  stomach  contents, 


BLOOD  IN  GASTRIC  CONTENTS  53 

giving  rise  to  the  so-called  coffee-ground  material,  of  brown- 
ish-black appearance. 

Weber's  Guaiac  Test. — The  detection  of  gastric  hemorrhage, 
especially  when  the  bleeding  is  small  in  amount,  is  accom- 
plished by  Weber's  guaiac  test. 

Technique  of  Examination. — A  small  quantity  of  the  gas- 
tric filtrate  is  rubbed  up  with  water;  one-third  its  volume 
of  glacial  acetic  acid  is  then  added  and  the  mixture  shaken 
up  with  ether  in  a  test-tube.  The  acetic  acid  changes  the 
hemoglobin,  if  present,  into  hematin,  which  is  in  turn  taken 
up  by  the  ether.  The  clear  supernatant  ether  is  then  poured 
off,  ten  drops  of  an  alcoholic  solution  of  resin  of  guaiac  are 
mixed  with  it,  and  lastly  twenty  to  thirty  drops  of  turpentine 
or  Huehnefeld's  reagent  are  added.  A  blue  color  appearing 
at  once  points  to  the  presence  of  blood  in  considerable  quan- 
tity. Delayed  appearance  of  the  blue  color  is  an  indication 
of  smaller  quantities  of  blood. 

It  has  been  known  for  some  time  that  in  carcinoma  of 
the  stomach  there  is  always  slight  gastric  hemorrhage. 
Chnicians  have  been  unable  to  tell  definitely  whether  the 
blood  found  in  the  stomach  contents  came  from  the  neo- 
plasm or  was  due  to  irritation  by  the  stomach  tube.  The 
slightest  irritation  by  the  stomach  tube  would  produce  a 
small  amount  of  invisible  blood,  which  would  respond  to 
the  guaiac  test.  Boas  was  the  first  to  examine  the  feces 
for  invisible  blood;  he  knew  the  blood  corpuscles  would 
degenerate,  but  the  hematin  crystals  should  be  found  in 
the  feces.  If  these  hematin  crystals  could  be  found  in  the 
feces,  with  other  signs  of  either  ulcer  or  cancer,  the  test 
would  be  valuable.  Examination  for  invisible  blood  in  the 
feces  is  of  great  importance,  since  many  clinicians,  among 
whom  are  Hartmann,  Boas,  Schloss,  Schmilinsky,  Einhorn, 
and  White,  report  the  constant  presence  of  occult  blood  in 
cases  of  gastric  ulcer  and  cancer.  The  term  "occult  blood" 
is  applied  to  minute  hemorrhages  discharging  in  the  gastro- 
intestinal canal,  too  small  to  be  discerned  macroscopically. 
By  the  time  the  blood  passes  through  the  whole  intestinal . 
canal  the  corpuscles  are  so  broken  down  that  they  cannot 


54  EXAMINATION  OF  THE  STOMACH  CONTENTS 

be  found  by  the  microscope.  The  tests  for  occult  blood  are 
chemical.  Steele  and  Butt,^  after  examining  720  stools,  con- 
cluded that  the  presence  of  occult  blood  was  of  decided 
diagnostic  value  only  in  gastric  and  duodenal  ulcer,  and 
cancer  of  the  gastro-intestinal  tract.  In  the  diagnosis  of 
carcinoma  and  gastric  ulcer,  sources  of  bleeding  that  have 
no  significance  must  be  excluded.  Since  the  test  is  ex- 
tremely sensitive,  very  small  amounts  of  blood  can  be 
detected.  There  is  great  Hability  to  error  in  determining 
the  site  of  the  hemorrhage.  Besides  epistaxis,  hemoptysis, 
and  hemorrhoids,  any  foodstuff  containing  hemoglobin  in 
any  amount  will  give  the  reaction.  Therefore,  the  diet 
must  be  a  blood-free  one  for-  three  days  previous  to  the  test. 

Weber's  guaiac  test  can  be  used  for  feces  just  as  it  can  be 
used  for  stomach  contents,  as  stated  on  page  35. 

Bemidin  Test  for  Occult  Blood. — This  test  is  very  sensitive. 
It  was  first  described  by  0.  and  R.  Adler,  and  has  been  sub- 
jected to  slight  modifications  by  Schlesinger  and  Hoist. 
The  test  is  as  follows : 

I.  One  gramme  of  benzidin  is  placed  in  a  test-tube  with 
about  2  Cc.  of  glacial  acetic  acid.  This  mixture  should  be 
freshly  prepared. 

II.  A  small  piece  of  feces  (the  size  of  a  pea)  is  rubbed 
up  with  water  and  placed  in  a  test-tube  and  boiled;  boiling 
destroys  the  oxidizing  ferments. 

III.  To  about  3  Cc.  of  peroxide  of  hydrogen  in  a  test- 
tube,  add  about  five  drops  of  the  above  glacial  acetic  acid- 
benzidin  mixture,  and  lastly  a  few  drops  of  the  boiled  feces. 

Blood  is  indicated  by  a  greenish  or  blue  color  (Plate  IV). 

The  advantage  of  the  benzidin  test  over  the  guaiac  test 
is  emphasized  by  White,"  whose  conclusions  are  as  follows: 

1.  Tests  for  invisible  hemorrhage  in  diseases  of  the  diges- 
tive organs  are  very  valuable  and  will  be  much  used  in  diag- 
nosis and  prognosis,  and  as  a  measure  of  the  results  of 
treatment.  It  is  important  to  recognize  and  use  the  best 
methods. 

1  American  Journal  of  the  Medical  Sciences,  July,  1905. 
^  Boston  Medical  and  Surgical  Journal,  June  10,  1909. 


PLATE  IV 


FIG.   2 


Benzidin  Test. 

lion.  Fig.  2:     Marked  reaction. 


BLOOD  IN  GASTRIC  CONTENTS  55 

2.  A  preliminary  step  is  necessary  in  both  guaiac  and 
benzidin  tests  to  exclude  sources  of  error  from  food  ferments. 
This  is  more  important  for  gastric  contents  than  for  feces. 
Acetic-acid-ether  extraction  is  best  in  the  guaiac  test,  and 
boiling  in  the  benzidin  test! 

3.  Metallic  salts,  potassium  iodide,  and  charcoal  must 
not  be  given  when  the  stomach  contents  are  to  be  tested  by 
the  benzidin  method. 

4.  Before  using  these  tests,  meat  and  fish  and  their 
juices  must  be  excluded  from  the  diet,  and  no  hemoglobin 
derivatives  should  be  administered  within  two  days  previous 
to  the  guaiac  test  or  three  or  four  days  previous  to  the 
benzidin  test. 

5.  Gastric  contents  should  be  examined  when  possible, 
but  feces  are  the  best  material  for  examination,  as  they 
alone  are  available  for  the  repeated  examination  which  is 
usually  necessary  for  diagnosis,  and  they  are  free  from  the 
source  of  error  involved  in  the  use  of  the  stomach  tube. 

6.  The  Weber  method  is  the  best  guaiac  test  for  routine 
clinical  work,  several  amounts  of  guaiac  being  used  as 
recommended  by  Schroeder. 

7.  The  original  Adler  benzidin  test  is  too  delicate  for 
clinical  work.  This  objection  has  been  overcome  in  the 
Schlesinger  and  Hoist  modification  of  the  test,  which  is  five 
to  seven  times  as  delicate  for  blood  in  gastric  contents  as 
the  guaiac  test,  but  only  about  twice  as  delicate  for  blood  in 
the  feces. 

8.  Schlesinger  and  Hoist's  modification  is  the  best  ben- 
zidin test  for  clinical  work.  It  has  all  the  clinical  value 
of  the  guaiac  test,  with  somewhat  greater  delicacy,  greater 
clearness,  and  much  simpler  technique,  and  acts  as  a  con- 
trol on  the  cleanliness  of  the  reagents  and  glassware. 

9.  Good  results  with  the  benzidin  test  depend  on  careful 
technique,  the  exclusion  of  oxidizing  ferments  in  raw  food, 
fresh  material  for  examination,  clean  glassware,  and  the 
quality,  strength,  and  proportion  of  the  reagents  used. 

10.  A  negative  benzidin  test  has  greater  value  than  a 
negative  guaiac  test  in  ruling  out  hemorrhage,  and  if  both 


56  EXAMINATION  OF  THE  STOMACH  CONTENTS 

tests  are  used  as  a  control  much  time  will  be  saved  by  using 
the  benzidin  test  first,  which  takes  only  two  minutes,  and 
if  negative,  renders  any  further  test  for  blood  unnecessary. 

11.  It  is  wise  to  control  the  benzidin  test  with  the  guaiac 
test  when  positive  results  are  found,  until  the  technique  is 
learned  and  tested  individuall}^ 

Einhorn's  Benzidin  Paper. — Einhorn^has  simplified  the  test 
by  making  a  benzidin  paper.  The  benzidin  paper  is  pre- 
pared by  moistening  filter  paper  with  a  saturated  solution  of 
benzidin  and  glacial  acetic  acid  and  drying  it.  In  prepar- 
ing the  paper,  as  well  as  in  making  the  test,  it  is  important 
to  avoid  contact  with  the  fingers,  as  a  drop  of  perspiration 
causes  a  reaction  similar  to  the  blood  reaction.  In  handhng 
the  paper  it  is  best  to  use  ivory-tipped  forceps  or  to  protect 
the  hands  by  means  of  a  towel. 

The  method  of  procedure  is  as  follows:  A  piece  of  ben- 
zidin paper  is  immersed  in  the  solution  to  be  examined,  and 
a  few  drops  of  hydrogen  peroxide  are  added.  The  piece  of 
paper  is  then  removed  (with  forceps)  and  placed  on  white 
porcelain,  so  that  the  color  reaction,  if  there  is  to  be  any, 
may  be  clearly  shown.  If  blood  is  present,  a  green  or  blue 
color  arises  in  a  few  seconds  to  a  minute;  should  the  color 
come  later,  the  showing  is,  according  to  Einhorn,  negative. 

Phenolphthalein  Test  for  Occult  Blood. — Boas"  prefers  the 
phenolphthalein  test  for  occult  hemorrhages  of  the  gastro- 
intestinal canal.  He  points  out  that  the  benzidin  test,  which 
demonstrates  blood  in  a  dilution  of  1  to  200,000,  is  altogether 
too  delicate;  it  indicates  the  minutest  quantities  of  alimen- 
tary (exogenous)  blood,  and  the  reaction  may  be  distinctly 
positive  after  three  or  four  days  of  meat-free  diet.  Weber's 
guaiac  test  is  less  susceptible,  but  inasmuch  as  the  substances 
which  disturb  the  test  must  be  extracted  by  alcohol  and 
ether,  there  are  certain  difhculties  in  the  way  of  its  practical 
application  not  present  in  the  phenolphthalein  test.  The 
phenolphthalein  test  is  based  on  the  fact  that  phenol- 
phthalein, in   an   alkaline   solution,  is   oxidized   by   blood 

'  Medical  Record,  June  S,  1907. 

^  Deutsche  mcdizinischc  Wochensclu ill,  11)11,  No.  J. 


EXAMINATION  OF  FECES  57 

pigment  so  that  the  solution  becomes  pink  or  rose-colored. 
The  phenolphthalein  reagent  is  prepared  as  follows:  1  Gm. 
of  phenolphthalein  and  25  Gm.  of  potassium  hydrate  are  dis- 
solved in  100  Cc.  of  water  to  which  is  added  10  Gm.  of  zinc 
powder.  The  mixture,  which  is  at  first  red,  is  boiled  over 
a  small  flame  under  constant  stirring  and  shaking  until 
complete  decoloration  has  taken  place  by  reduction.  The 
hot  solution  is  then  filtered.  For  preservation  a  small  excess 
of  zinc  powder  may  be  added. 

The  demonstration  of  blood  is  carried  out  as  follows: 
Firm  feces  are  triturated  with  water  until  they  are  of  a 
fluid  consistency.  Acidify  5  Cc.  of  the  fecal  mixture  in  a 
test-tube  with  glacial  acetic  acid,  shake,  add  an  equal 
volume  of  ether,  and  carefully  agitate  the  contents  in  the 
test-tube  to  extract  the  fecal  mixture,  carefully  avoiding  the 
formation  of  an  emulsion.  Decant  the  ethereal  solution 
into  a  clean  test-tube,  and  add  to  this  solution  20  drops  of 
the  phenolphthalein  reagent,  shake  slightly,  and  finally 
add  3  to  4  drops  of  peroxide  of  hydrogen.  If  blood  pigment 
be  present,  a  rose  or  intensely  pink  color  will  result,  which 
will  persist  for  some  time  if  there  is  much  blood.  It  will 
not,  indeed,  be  necessary  to  add  peroxide  of  hydrogen  to  the 
fecal  solution  if  there  is  much  blood  present.  The  principal 
advantage  of  this  test  consists  in  the  characteristic  reaction, 
the  possibility  of  differentiating  between  the  presence  of 
large  and  small  quantities  of  blood,  the  permanency  of  the 
reagent,  and  simplicity  of  preparation. 


EXAMINATION   OF  FECES 

In  endeavoring  to  test  the  functions  of  the  intestine, 
Adolf  Schmidt'  devised  a  test  diet  which  enabled  him  to  get 
an  insight  into  the  functions  of  the  stomach  also. 

Schmidt's  Test  Diet. — Schmidt's  general  test  diet  is  as 
follows : 

1  Adolf  Schmidt,  Examination  of  the  Function  of  the  Intestine  by  Means 
of  the  Test  Diet.     Translated  by  Charles  D.  Aaron,  Philadelphia,  1909,  p.  11. 


58  EXAMINATION  OF  THE  STOMACH  CONTENTS 

On  arising  in  the  morning :  One-half  liter  of  milk ;  tea  or 
cocoa  (if  possible  with  milk),  together  with  one  roll  with 
butter  and  one  soft-boiled  egg. 

Breakfast:  One  dish  of  oatmeal  cooked  in  milk  and 
strained  (salt  or  sugar  permissible) .  Gruel  or  porridge  may, 
under  certain  conditions,  also  be  given. 

At  noon:  One-fourth  pound  of  finely  chopped  lean  beef, 
broiled  rare  with  butter  (the  interior  raw) ,  and  along  with  it 
not  too  small  a  portion  of  potato  broth  (well  strained). 

In  the  afternoon:    Same  as  in  the  morning,  but  no  egg. 

In  the  evening:  One-half  liter  of  milk  or  one  plate  of  soup 
(as  in  the  morning),  together  with  a  buttered  roll  and  one 
or  two  eggs  soft  boiled  or  scrambled. 

There  are  four  fundamentals  of  the  Schmidt  test  diet 
which  must  be  strictly  observed: 

1.  A  certain  moderate  measure  of  milk  (one-half  to  one 
and  one-half  liters),  which  may  be  boiled  entirely  with 
the  foods. 

2.  One  hundred  grammes  of  white  bread  (zwieback, 
crackers,  etc.). 

3.  A  goodly  portion  (100  to  250  grammes)  of  potato  broth. 

4.  One-quarter  pound  of  chopped  beef,  a  portion  at  least 
of  which  must  remain  raw  or  half-raw. 

The  test  diet  is  given  for  three  days  or  longer,  until  a 
stool  is  obtained  which  comes  with  certainty  from  this  diet. 

If  connective-tissue  residues  appear  in  the  feces,  it  is  a 
sign  of  disturbance  in  stomach  digestion.  Of  all  the  diges- 
tive secretions,  as  Schmidt  has  shown,  the  gastric  juice  alone 
can  digest  raw  connective  tissue.  The  stomach  alone  is  at 
fault  if  connective  tissue  appears  in  the  feces.  In  most 
eases  it  is  a  question  of  subacidity  or  achylia,  and  the  dis- 
turbance may  become  so  severe  that  the  connective  tissue 
is  discharged  in  quantities  as  a  fine  down  intermingled  with 
the  whole  stool. 

If  macroscopically  discernible  muscle  residues  appear  in  the 
feces,  this  is  a  sign  of  disturbance  of  digestion  in  the  small 
intestine.  The  stomach  takes  only  a  small  part  in  the  solu- 
tion of  muscle,  by  far  the  larger  part  falling  to  the  intes- 


EXAMINATION  OF  FECES  59 

tine.  This  is  proved  by  the  fact  that  even  in  cases  of 
complete  achyUa  gastrica,  muscle  fragments  never  appear 
in  the  feces.  If  the  small  intestine  does  not  perform  its 
functions  normally,  muscle  fragments  are  found  in  the  feces. 
It  can  be  stated  with  certainty  that  the  difficulty  is  in 
the  small  intestine,  inasmuch  as  the  large  intestine  serves 
only  as  a  reservoir  without  digestive  action.  Connective 
tissue  and  muscle  together,  as  meat  remains,  indicate  dis- 
turbances in  both  the  stomach  and  the  small  intestine. 

The  Bead  Test. — Einhorn^  has  devised  a  new  method  of 
testing  the  functions  of  the  digestive  apparatus,  which  is 
known  as  the  Bead  Test.  It  consists  in  giving  the  patient 
beads  with  various  food  substances  attached,  and  examining 
the  feces  with  the  stool  sieve  until  all  the  beads  are  recovered. 
The  latter  are  then  inspected  with  regard  to  the  presence  or 
absence  of  the  attached  foods;  thus  it  is  seen  whether  these 
have  passed  the  digestive  tract  unaltered,  or  whether  they 
have  been  digested. 

Ordinarily  the  following  six  test  substances  are  given: 
(1)  Catgut;  (2)  fishbone;  (3)  meat;  (4)  potato;  (5)  mutton 
fat;  (6)  thymus  gland.  Physiologically  the  first  two  sub- 
stances (catgut  and  fishbone)  are  usually  digested  in  the 
stomach,  and  the  remaining  four  (meat,  potato,  mutton  fat, 
thymus)  in  the  intestine. 

All  the  beads  (or  at  least  the  greater  part  of  them)  usually 
appear  in  the  stool  under  normal  conditions  in  one  or  two 
days.  The  beads  should  be  either  all  empty  or  carry  but  a 
trace  of  fat  or  thymus  (possibly  fishbone) .  Deviations  from 
this  rule  point  to  pathologic  conditions. 

With  regard  to  the  functions  of  the  digestive  apparatus 
the  following  conclusions  may  be  drawn:  In  case  all  the 
beads  (or  the  greater  number)  appear  in  a  much  shorter  time 
than  twenty-four  hours,  there  is  accelerated  motility;  if 
they  do  not  appear  until  after  forty-eight  hours,  motility  is 
retarded.  The  digestive  function  is  good  if  all  the  beads  are 
empty  or  if  there  are  but  traces  of  fat  or  thymus  (also 

^  Journal  Araerican  Medical  Association,  February  2,  1907. 


60  EXAMINATION  OF  THE  STOMACH  CONTENTS 

fishbone)  left.  The  survival  of  catgut  or  meat,  potato,  much 
fat  or  much  thymus,  always  indicates  a  poor  digestive 
function  for  the  food  substance  in  question.  If  all  these 
test  substances  reappear  in  the  stool,  an  absolutely  poor 
digestive  function  exists.  By  stringing  the  different  test 
beads  and  tying  them  together  on  a  silk  thread,  they  all 
appear  in  one  stool  and  the  period  of  examination  is  thus 
considerably  abbreviated.  In  order  to  diminish  the  number 
of  beads  and  also  the  length  of  the  string,  two  food  sub- 
stances may  be  fastened  to  each  bead;  for  instance,  catgut 
and  fishbone,  meat  and  thymus,  potato  and  fat — only  three 
beads.  Instead  of  leaving  the  ends  of  the  string  free,  they 
may  be  tied  together  so  as  to  form  a  loop.  The  bead  string 
is  put  into  a  gelatin  capsule  and  thus  administered. 

Preparation  of  Food  Beads. — 1.  Catgut. — Take  raw  catgut 
No.  00,  draw  it  through  the  bead  and  tie  the  ends  together. 

2.  Fishbone. — As  the  ordinary  fishbone  breaks  when  tied 
in  a  knot,  it  is  best  to  use  the  long  bones  from  a  pickled 
herring.  The  bones  are  washed  in  water  first,  then  rubbed 
off  with  a  cloth.  They  are  then  kept  in  water  in  a  bottle. 
When  wanted  they  are  taken  out  of  the  water,  drawn 
through  the  bead  and  tied  in  the  same  manner  as  the  catgut. 

3.  Meat. — The  muscle  fibres  of  raw  beef  are  cut  length- 
wise in  the  direction  of  the  fibres  and  in  pieces  5  to  6  Cm. 
long,  1  Cm.  thick.  These  are  preserved  in  a  bottle  of  alcohol. 
Take  a  piece  of  meat  from  the  alcohol  bottle,  tear  off  length- 
wise a  muscle  fibre  2  to  3  cm.  long,  1  mm.  thick,  draw  it 
through  the  bead  and  allow  the  ends  to  overlap,  then  tie 
the  ends  fast  together  over  the  bead  with  a  silk  thread. 

4.  Thymus. — Raw  sweetbread  from  the  calf  is  cut  in 
cubes  and  preserved  in  alcohol.  For  use,  lay  a  small  piece 
(about  2  cm.)  within  a  small  square  of  gauze,  fold  the  four 
ends  of  the  gauze  together  and  tie  with  thread,  so  that  the 
piece  of  thymus  Hes  enclosed  as  in  a  purse;  then  fasten 
the  gauze  purse  to  a  bead,  passing  one  end  of  the  thread 
through  the  eyelet. 

5.  Mutton  Fat. — Beads  with  a  largo  opening  (1.5  to  2  mm. 
in  diameter)  should  be  dropped  in  hot  rendered  mutton  fat 


IXDIRECT  METHODS  OF  GASTRIC  ANALYSIS  61 

and  after  a  minute  taken  out  with  forceps  and  placed  in 
a  vessel  of  cold  water.  This  congeals  the  fat.  Then  they 
are  laid  on  a  piece  of  pure  filter  paper  and  allowed  to 
remain  there  until  thoroughly  dried.  The  beads  thus  pre- 
pared can  be  kept  as  long  as  desired  and  are  ready  when 
wanted. 

6.  Potato. — Cook  a  piece  of  unpeeled  potato  in  boiling 
water  for  two  minutes,  take  it  out  and  cool  it,  cut  off  a  piece 
(with  peel)  about  1  cm.  long,  0.5  cm.  wide,  and  1.5  to  2 
mm.  thick,  and  attach  it  to  a  bead. 

Two  or  more  food  substances  may  be  attached  to  one 
bead;  for  instance,  catgut  and  fishbone,  meat  and  thymus. 
The  test  beads,  prepared  for  use,  can  all  be  kept  on  hand, 
with  the  exception  of  the  potato,  which  must  always  be 
freshly  boiled  Meat  and  thymus  beads  are  best  kept  in 
alcohol.  Catgut,  fishbone,  and  fat  beads  are  simply  preserved 
dry.  The  bead  string  is  placed  in  a  gelatin  capsule  and  so 
administered — best  shortly  after  a  meal.  The  bead  test 
should  be  used  in  all  cases  in  which  a  thorough  knowledge 
of  the  working  functions  of  the  digestive  apparatus  is  desired. 

The  bead  test  is  not  permissible  in  pronounced  stenoses 
of  the  digestive  tract — stricture  of  the  esophagus,  stomach, 
or  intestine. 


INDIRECT  METHODS  OF  GASTRIC  ANALYSIS 

A  number  of  methods  are  in  vogue  for  the  examination 
of  the  functioning  powers  of  the  stomach  without  removing 
the  gastric  contents.  While  such  methods  fail  to  determine 
the  exact  condition  of  the  acidity  or  of  the  activity  of  fer- 
ments, much  may  be  learned  by  means  of  them  regarding 
gastric  motihty  as  well  as  the  digestive  powers  of  the  stomach. 

Giinzburg's  Method  of  Testing  the  Absorptive  Power  of  the  Stomach. 
— Two  centigrammes  of  potassium  iodide  are  placed  in  a 
section  of  very  thin  though  strongly  vulcanized  rubber 
tubing  about  three-quarters  of  an  inch  in  length.  The  ends 
of  the  tubing  are  folded,  and  tied  with  threads  of  fibrin 


62  EXAMINATION  OF  THE  STOMACH  CONTENTS 

hardened  in  alcohol.  To  make  sure  that  both  ends  are 
water-tight,  the  tube  should  be  placed  in  water  and  allowed 
to  remain  for  several  hours,  the  water  being  then  tested  for 
potassium  iodide.  Should  none  of  the  drug  be  found,  the 
patient  is  directed  to  swallow  the  package  three-quarters  of 
an  hour  after  having  partaken  of  an  Ewald  test  meal.  Free 
hydrochloric  acid  of  the  stomach  will  dissolve  the  fibrin 
threads  and  liberate  the  potassium  salt  into  the  stomach. 
The  saliva  should  be  tested  for  potassium  iodide  at  intervals 
of  fifteen  minutes.  When  the  acid  secretion  is  below  normal 
the  salivary  reaction  will  be  delayed.  In  cases  in  which  the 
acid  secretion  is  wholly  absent  the  potassium  salt  may  not 
appear  in  the  saliva  for  at  least  six  hours. 

SahJi's  Desmoid  Test. — By  the  simple  means  of  investi- 
gation of  the  functions  of  the  stomach  described  by  Sahli 
in  1905  the  physician  may  avoid  the  annoyance  that 
certain  patients  experience  when  gastric  contents  are  with- 
drawn by  means  of  the  stomach  tube  for  analj^sis.  The 
desmoid  test  is  based  upon  the  observation  of  Adolf 
Schmidt,  that  the  digestion  of  raw  connective  tissue  is 
confined  to  the  stomach.  Raw  connective  tissue  passing 
through  the  stomach  undigested  is  not  affected  by  the  pan- 
creatic and  intestinal  juices,  but  is  ejected  with  the  feces 
unchanged.  The  details  of  the  test  are  as  follows:  Two 
small  squares  of  rubber  dam,  such  as  dentists  use,  are  made 
into  bags;  into  one  is  placed  one  decigramme  of  iodoform 
and  into  the  other  five  centigrammes  of  methylene  blue. 
The  bags  are  closed  and  tied  tightly  with  No.  00  raw  catgut 
that  has  been  permitted  to  dry  but  has  not  been  treated 
chemically.  The  patient  is  instructed  to  swallow  the  two 
rubber  bags  with  their  contents.  Under  normal  conditions 
of  gastric  secretion  the  catgut  is  duly  dissolved  and  the 
contents  of  the  bags  liberated  into  the  stomach ;  iodine  will 
therefore  shortly  appear  in  the  saliva  and  the  methylene 
blue  in  the  urine.  Beginning  three  hours  after  the  bags  are 
swallowed,  the  urine  and  the  saliva  should  be  tested  at  one- 
hour  intervals.  Should  the  rubber  bags  with  their  contents 
pass  through  the  digestive  canal  unchanged,  gastric  secretion 


IXDIRKCT  METHODS  OF  GASTRIC  AXALYSIS  03 

is  either  very  much  retarded  or  entirely  absent ;  in  such  cases 
no  change  is  detected  in  the  saUva  or  urine.  The  best  time 
for  making  the  test  is  immediately  after  the  noon  meal. 
Under  normal  conditions,  iodine  will  appear  in  the  saliva 
in  about  two  hours  and  methylene  blue  in  the  urine  within 
six  hours.  Any  deviation  from  this  indicates  hyperacidity 
or  subacidity,  depending  upon  the  interval  between  the 
administration  of  the  test  agents  and  their  presence  in  the 
saliva  or  urine. 

Einhorn^  declares  Sahh's  desmoid  test  to  be  unreliable, 
maintaining  that  catgut  will  dissolve  in  the  intestine  as  well 
as  in  the  stomach. 

Salomon's  Test. — The  principle  underlying  this  test  is 
the  fact  that  carcinoma  secretes  albumin,  which  becomes 
mixed  with  the  gastric  contents.  The  diet  of  the  patient 
for  twenty-four  hours  prior  to  the  test  should  be  absolutely 
free  from  protein.  At  the  beginning  of  this  period  he  is 
given  a  morning  meal  of  milk  and  gruel  and  a  mid-day  meal 
of  bouillon  with  coffee  or  tea.  Late  in  the  evening  the 
stomach  should  be  washed  out  with  large  quantities  of  pure 
water  until  the  return  water  is  clear.  The  following  morn- 
ing the  fasting  stomach  is  washed  twice  with  400  Cc.  of 
physiologic  salt  solution,  the  same  solution  being  used  each 
time.  This  solution  is  then  tested  by  the  Kjeldahl  method 
for  the  total  amount  of  nitrogen,  and  by  Esbach's  method 
for  the  quantitative  estimation  of  albumin. 

Salomon  found  in  cases  of  gastric  cancer  20  to  70 
milligrammes  of  nitrogen  and  from  0.00625  to  0.05  per  cent, 
of  albumin  to  each  100  Cc.  of  the  fluid  that  had  been  used 
in  lavage.  In  non-malignant  cases,  according  to  this  inves- 
tigator, no  albumin  could  be  detected,  and  the  amount  of 
nitrogen  varied  from  0  to  16  milligrammes  in  each  100  Cc. 

Neubauer  and  Fischer  Test  for  Carcinoma. — Neubauer  and 
Fischer"  have  presented  a  method  for  the  early  diagnosis  of 
carcinoma  of  the  stomach.  The  amino-acids,  products  of 
proteolysis,  are  normally  formed  only  in  the  intestine.    These 

1  Journal  of  the  American  Medical  Association,  May  12,  1906. 

^  Deutschen  Archiv  ftir  klinische  Medizin,  Band  xcvii,  Hefte  5  and  6. 


64  EXAMINATION  OF  THE  STOMACH  CONTENTS 

authors  have  found  that  carcinoma  of  the  stomach  will 
secrete  a  ferment  which,  unhke  pepsin,  exerts  a  peptid- 
splitting  action.  The  detection  of  this  ferment  in  the 
stomach  contents  can  be  used  with  other  cUnical  data  in 
diagnosis  of  carcinoma.    The  test  is  performed  as  follows: 

One-half  to  three-quarters  of  an  hour  after  taking  a 
test  breakfast  the  contents  of  the  stomach  are  removed 
and  examined  for  blood  and  bile.  If  there  is  no  redness, 
and  if  the  tests  for  blood  and  bile  are  negative,  the  following 
ferment  test  may  be  made: 

To  about  10  Cc.  of  the  filtered  contents  add  a  small 
quantity  of  glycyltryptophan,  color  with  a  layer  of  toluol, 
and  allow  to  stand  in  an  incubator  for  twenty-four  hours. 
Insert  a  pipet  under  the  layer  of  toluol,  take  up  a  portion  of 
the  liquid  (2  to  3  Cc),  transfer  this  to  a  test-tube,  and  add 
a  few  drops  of  3-per-cent.  acetic  acid.  Then  from  a  bottle 
containing  bromine  vapor  carefully  allow  some  of  the  vapor 
to  fall  into  the  test-tube,  so  that  a  slightly  brown  coloring 
is  noticeable  in  the  upper  part  of  the  tube.  If,  upon  shaking, 
the  solution  assumes  a  rose  shade,  free  trj^ptophan  is  present. 
If  the  rose  color  does  not  appear,  the  operation  should  be 
carefully  repeated  until  excess  of  bromine  is  indicated  by  the 
liquid  assuming  a  shghtly  yellow  tint,  when  the  test  may  be 
considered  negative.  Great  caution  should  be  observed  to 
avoid  adding  the  bromine  vapor  too  fast,  as  an  excess  will 
cause  the  pink  color  to  appear  and  disappear  again  so  quickly 
as  to  elude  even  the  practiced  eye. 

Instead  of  the  bromine  vapor  a  solution  of  calcium  hypo- 
chlorite may  be  used.  It  should  be  about  one-fifth  the 
strength  of  the  semi-saturated  solution  used  in  the  test  for 
indican.  Owing  to  the  instabiUty  of  calcium  hypochlorite, 
the  solution  before  being  used  should  be  tested  with  a  solu- 
tion of  potassium  iodide  (yellowish-brown  color  through 
liberation  of  iodine).  The  reagent  is  then  added  drop  by 
drop  by  means  of  a  pipet.  Free  tryptophan,  from  the 
decomposition  or  splitting  up  of  glycyltryptophan,  is  indi- 
cated by  a  rose  color,  which  disappears  with  excess  of  the 
reagent.     In  case  the  test  is  negative  it  may  be  repeated  in 


SKIN   RE  ACTIOS  IN   CARCINOMA  65 

twenty-four  hours,  although  the  decomposition  of  glycyl- 
tryptophan  taking  place  in  the  first  twenty-four  hours  after 
it  is  added  to  the  gastric  contents  under  investigation  is  the 
only  one  which  has  any  significance.  In  case  of  doubt  it  is 
better  to  examine  a  fresh  sample  of  gastric  contents. 


SKIN   REACTION  IN   CARCINOMA 

In  the  growth  and  breaking  down  of  malignant  tumors 
it  has  been  found  by  clinical  investigation  that  substances 
are  formed  and  set  free  that  act  as  poisons  to  the  red  blood 
cells.  To  these  substances,  or  lysins,  the  anemia  and  cachexia 
of  malignant  disease  has  been  ascribed.  Elsberg,  Neuhof, 
and  Geist,^  reasoning  on  the  assumption  that  the  blood 
serum  of  patients  suffering  from  malignant  disease  contains 
hemolysins,  while  that  of  normal  individuals  or  those 
suffering  from  other  diseases  does  not,  maintain  that  in 
this  blood  phenomena  there  is  possible  a  valuable  agency  for 
the  diagnosis  of  malignant  disease.  They  have  accordingly 
made  use  of  the  hemolytic  action  of  the  blood  serum  of 
cancerous  patients  by  a  new  method.  They  inject  sub- 
cutaneously  into  the  forearm  of  the  suspected  cancer 
patient  five  minims  of  a  suspension  of  20-per-cent. 
washed  human  blood  corpuscles  in  salt  solution.  The 
hemolysins  in  the  blood  serum  of  the  cancer  patient  attack 
the  corpuscles  so  that  a  reaction  shows  in  two  to  eight 
hours.  The  skin  at  the  site  of  injection  exhibits  the  effect 
in  a  color  varying  from  brownish-red  to  bluish.  The  reaction 
was  found  to  be  positive  in  89.9  per  cent,  of  cancer  cases. 
We  have  in  these  researches  results  that  may  lead  to  a 
method  which  will  enable  one  to  make  an  early  positive 
diagnosis  of  cancer  of  the  stomach. 

1  American  Journal  of  the  Medical  Sciences,  February,  1910. 


66  EXAMINATION  OF  THE  STOMACH  CONTENTS 


MOTOR  FUNCTION   OF   THE    STOMACH 

The  motor  function  of  the  stomach  may  be  determined 
by  the  introduction  of  food  and  subsequent  examination 
of  the  stomach  contents.  For  this  purpose  von  Leube's 
test  meal  is  employed,  which  consists  of  a  plate  of  soup, 
beef  steak,  a  roll,  and  a  glass  of  water;  or  Riegel's,  con- 
sisting of  400  Cc.  of  beef  broth,  200  grammes  of  beefsteak, 
50  grammes  of  bread,  and  200  Cc.  of  water.  After  this  meal 
the  patient  must  not  partake  of  anything  during  the  next 
seven  hours.  At  the  end  of  the  seven-hour  period  the  stom- 
ach is  washed  out,  according  to  von  Leube,  in  such  a  manner 
that  the  funnel  is  twice  filled  with  about  a  half-liter  of  water. 
If  no  food  remnants  appear,  it  may  be  concluded  that  the 
motor  function  of  the  stomach  is  normal. 

For  practical  purposes  the  motor  function  of  the  stomach 
may  be  deterinined  by  means  of  a  test  breakfast.  Under 
normal  conditions  the  test  breakfast  leaves  the  stomach  in 
two  hours  at  most;  so  if  at  the  end  of  two  hours  large  quanti- 
ties of  fluid  or  food  remnants  are  present,  the  motor  function 
of  the  stomach  may  be  regarded  as  impaired. 

According  to  Boas,  motor  insufficiency  ma}^  be  due  either 
to  weakness  of  the  expelling  force  or  to  obstacles  to  expul- 
sion. The  former,  which  includes  myasthenia  and  paresis, 
may  occur  in  the  following  conditions:  (1)  Congenital  (rare) ; 
(2)  the  result  of  certain  constitutional  diseases,  such  as 
anemia,  chlorosis,  pulmonary  tuberculosis,  leukemia,  dia- 
betes, and  syphihs,  or  as  a  sequel  of  acute  infectious  dis- 
eases or  in  association  with  chronic  catarrh;  (3)  myasthenia 
may  occur  independently,  due  to  irregular  modes  of  Uving, 
and  is  frequently  combined  with  enteroptosis;  (4)  or  it 
may  result  from  specific  diseases  of  the  musculature  of  the 
stomach,  as  in  flattened  growth  of  carcinoma  of  the  smaller 
curvature  or  the  anterior  wall  of  the  stomach — in  such 
conditions,  though  insufficiency  cannot  be  ascertained  by 
physical  examination,  the  motor  function  may  be  so  im- 
paired that  food  remnants  from  the  evening  meal  are  found 


PERMEABILITY  OF  THE  PYLORUS  67 

in  the  fasting  stomach  in  the  morning;  (5)  neurasthenia, 
buUmia,  polyphagia,  as  well  as  local  irritation  of  the  nerve 
endings,  occasionally  lead  to  paralysis  of  the  musculature 
of  the  stomach. 

Obstructions  to  the  expulsion  of  the  stomach  contents 
may  occur  in  the  wall  of  the  stomach  itself,  as  in  gastric 
ulcer  or  carcinoma  of  the  pylorus;  it  sometimes  happens  that 
benign  tumors  obstruct  the  pyloric  exit.  In  rare  instances 
there  is  congenital  stenosis  of  the  pylorus  as  well  as  hyper- 
trophic thickening  of  the  pyloric  muscle  fibres. 

PERMEABILITY  OF  THE  PYLORUS 

Einhorn^  has  described  a  new  method  for  testing  the 
permeability  of  the  pylorus.  The  patient  is  instructed  to 
swallow  beads  filled  with  methylene  blue  and  coated  with 
mutton  tallow.  Inasmuch  as  fat  is  dissolved  in  the  duo- 
denum, a  green  or  blue  colored  urine  would  indicate  that 
the  bead  had  passed  the  pylorus  and  that  its  contents  had 
been  absorbed.  Under  normal  conditions  the  bead  will  pass 
into  the  duodenum,  the  tallow  coating  be  dissolved,  and  the 
methylene  blue  appear  in  the  urine  in  three  to  five  hours.  In 
order  to  ascertain  whether  the  bead  enters  the  duodenum, 
Einhorn  makes  a  control  test  consisting  of  a  second  bead 
similarly  prepared  and  anchored  in  the  stomach  at  a  dis- 
tance of  fifty  centimeters  from  the  lips.  The  first  bead  is 
anchored  at  a  distance  of  seventy-five  centimeters  from 
the  lips,  which  is  sufficient  to  allow  it  to  pass  through  the 
pylorus  and  well  into  the  duodenum.  A  similar  test  has 
been  instituted  by  Einhorn  in  which  he  employs  pieces  of 
agar  saturated  with  tincture  of  dimethylamidoazobenzol; 
these  are  placed  in  gauze  and  tied  to  the  beads.  The 
dimethyl-agar  that  is  withdrawn  directly  from  the  free 
hydrochloric  acid  of  the  stomach  will  be  red;  that  which 
has  passed  into  the  duodenum  will,  on  withdrawal,  exhibit 
no  change  in  color. 

1  New  York  Medical  Journal,  June  20,  1908. 


68 


EXAMINATION  OF  THE  STOMACH  CONTENTS 


Fig.  5 


The  duodenal  bucket  devised  by  Einhorn  (Fig.  5)  is  much 
smaller  than  the  stomach  bucket.  It  is  fastened  to  the  end 
of  a  braided  silk  thread  over  seventy 
centimeters  in  length,  and  is  administered 
to  the  patient  in  a  gelatin  capsule  an 
hour  after  a  small  meal.  The  bucket 
should  be  left  in  the  intestinal  canal 
three  hours,  during  which  time  the 
patient  should  not  partake  of  any  food. 
The  thread  at  its  free  extremity  should 
be  tied  to  the  ear  so  that  it  cannot  go 
beyond  the  75-centimeter  mark.  After 
the  expiration  of  three  hours  the  bucket 
is  slowly  withdrawn.  The  resistance 
offered  at  the  esophageal  entrance  to 
the  stomach  can  be  overcome  by  the 
patient  going  through  the  act  of  swallow- 
ing. Einhorn  advises  that  the  patient 
swallow  the  bucket  before  retiring  at 
night  and  that  it  be  withdrawn  in  the 
morning  while  the  stomach  is  empty. 
The  contents  of  the  bucket  will  be 
found  to  be  yellowish  in  appearance, 
owing  to  the  presence  of  bile  in  the 
duodenum.  Einhorn  assures  himself  of 
the  presence  of  the  bucket  in  the  duo- 
Duodenai  bucket.        dcnum  by  means  of  the  Roentgen  rays. 


MICROSCOPIC  EXAMINATION  OF  STOMACH  CONTENTS 

Microscopic  examination  may  be  made  of  the  gastric 
contents  as  withdrawn  from  the  stomach  by  the  stomach 
tube  after  the  administration  of  a  test  meal,  or  from  the 
vomitus.  Undue  importance  should  not  be  attached  to 
the  presence  of  meat  shreds  (Fig.  7,  C)  or  starch  granules, 
(Fig.  6,  C),  which  are  practically  never  absent  from  the 
gastric  juice.  Normal  gastric  juice  may  also  contain  small 
particles  of  mucus,  a  few  bacilli,  and  some  yeast  cells. 


MICROSCOPIC  EXAMINATION  OF  STOMACH  CONTENTS     ()9 

In  motor  insufficiency,  remains  of  food  which  has  been 
introduced  many  hours  previously  may  be  found  in  the 
form  of  numerous  fat  globules  or  fatty  acid  crystals  (Fig. 
6,  B  and  E),  vegetable  fibres  and  plant  cells  (Fig.  6,  D),  as 
well  as  a  few  red  blood  corpuscles  which  have  come  from 
abrasion  of  the  pharynx  by  the  stomach  tube.  Any  red 
blood  cells  found  are  apt  to  be  altered  in  appearance  as  a 
result  of  the  action  of  the  hydrochloric  acid  of  the  stomach. 


Fig.  6 


A,  epithelial  cells;    B,  fat  globules;    C,  starch  granules;   D,  plant  cells;    E,  fatty  crystals; 

F,  sarcinse. 


The  Boas-Oppler  bacillus  (Fig.  7,  B)  is  found  in  75  to  85 
per  cent,  of  all  cases  of  gastric  cancer  and  seldom  in  non- 
malignant  disease.  It  is  found  more  frequently  when  lactic 
acid  is  present  in  large  amounts,  and  may  be  absent  in  the 
incipient  stages  of  carcinoma.  It  is  three  to  ten  microns  in 
length  and  one  micron  broad.  These  bacilli  are  frequently 
found  joined  end  to  end,  forming  very  long  chains.  They 
stain  by  the  ordinary  method  as  well  as  by  Gram's  method, 


70 


EXAMINATION  OF  THE  STOMACH  CONTENTS 


and  take  on  a  brown  color  when  treated  with  iodine.  This 
latter  feature  distinguishes  them  from  the  Leptothrix  bue- 
calis,  which  stains  blue  with  iodine.  The  Boas-Oppler 
bacillus  is  not  infalhbly  pathognomonic  of  carcinoma;  it  is 
present  on  rare  occasions  in  the  dilatation  of  benign  stenosis 
of  the  pylorus. 

Fig.  7 


A,  pus  cells;   B,  Boas-Oppler  bacilli;   C,  muscle  fibre. 


Sarcinse  are  occasionally  found  in  normal  gastric  juice, 
and  especially  in  cases  of  gastric  dilatation  when  there  is 
marked  fermentation,  with  hydrochloric  acid  present;  this 
microorganism  consists  of  cocci  arranged  in  squares  or  tetra- 
hedra  (Fig.  6,  F).  It  is  of  no  pathologic  significance  other 
than  being  indicative  of  stagnation.  A  large  number  of 
yeast  cells  are  found  along  with  the  sarcinse. 

Protozoa  have  been  found  in  the  gastric  contents.  Flagel- 
lates, amebae,  and  monads  are  among  the  more  fretiuent 
protozoan  types  found.  According  to  Simon,  "From  the 
available  data  there  can  be  no  question  that  the  presence 


CHANGliJS  IN  GASTRIC  SECRETION  ~i 

of  protozoa  in  the  stomach  contents  is  suggestive  of  non- 
obstructive carcinoma." 

In  cases  of  chronic  gastritis,  ulcer,  hyperchlorhydria,  and 
especially  cancer,  small  shreds  of  mucous  membrane  are 
sometimes  found  in  the  gastric  contents  withdrawn  by  the 
tube.  Such  tissue  fragments  should  be  carefully  studied 
under  the  microscope,  since  it  is  sometimes  possible  to  make 
a  diagnosis  of  cancer  thereby. 

Various  types  of  crystals  are  occasionally  noted  in  the 
gastric  contents,  among  which  may  be  mentioned  bile 
acids,  cholesterin,  fatty  acids,  leucin,  tyrosin,  and  calcium 
oxalate. 


CHANGES  IN  GASTRIC  SECRETION  DUE  TO  PATHOLOGIC 
CONDITIONS 

1.  Gastric  Neuroses. — The  gastric  findings  in  nervous 
dyspepsia  show  the  acidity  to  be  normal  or  either  above 
or  below;  the  ferments  are  fairly  constant.  The  fact  that 
the  acidity  varies  from  day  to  day,  being  one  day  excessive 
and  the  next  decreased,  is  characteristic  of  the  disease. 
Hemmeter  gave  the  name  ^'heterochylia"  to  this  condition. 
In  chronic  gastritis  the  acidity  remains  constant,  while  in 
nervous  dyspepsia  it  is  subject  to  variation.  The  ferments, 
which  are  diminished  in  chronic  gastritis,  are  usually  normal 
in  nervous  dyspepsia.  The  findings  in  chronic  gastritis  reveal 
much  mucus,  in  nervous  dyspepsia  little  or  none.  The  former 
condition  is  associated  with  dietetic  errors,  the  latter  with  a 
neurotic  temperament. 

2.  Hyperacidity;  Hyperchlorhydria. — This  term  is  used  to 
designate  the  secretion  of  gastric  juice  of  excessive  acidity, 
the  amount  of  free  hydrochloric  acid  varying  from  a  small 
to  a  high  degree  above  the  normal.  The  normal  acidity  is 
between  40  and  60  degrees.  Usually  an  increased  total 
acidity  is  found  along  with  the  increase  in  free  hydro- 
chloric acid.  Hyperacidity  is  said  to  exist  when  there  is  a 
constant  of  more  than  60  degrees,  0.2  per  cent,  of  free  hydro- 


72  EXAMINATION  OF  THE  STOMACH  CONTENTS 

chloric  acid.  Hyperacidity  or  hyperchlorhydria  may  be 
due  to  neuroses,  or  to  pathologic  changes  in  the  mucous 
membrane  of  the  stomach  itself.  Often  there  is  diminished 
motility  due  to  pylorospasm,  and  as  a  result  stagnation  of 
gastric  contents  with  fermentation.  In  such  cases  the  acidity 
may  amount  to  150  degrees  or  over.  Erythrodextrin  is 
present  in  large  quantities. 

3.  Hypersecretion;  Gastrosuccorrhea ;  Gastrorrhea;  Gastrochy- 
lorrhea. — By  this  is  understood  an  excessive  secretion  of 
gastric  juice  in  the  total  or  almost  total  absence  of 
stimulus  to  the  secretive  function  of  the  stomach.  Hyper- 
secretion, or  gastrosuccorrhea  as  it  has  been  called,  is 
always  a  pathologic  condition.  The  diagnosis,  as  stated 
elsewhere,  is  confirmed  by  the  finding  of  a  pathognomonic 
quantity  of  gastric  juice,  containing  both  hydrochloric  acid 
and  pepsin,  in  the  fasting  stomach.  The  quantity  should  be, 
according  to  Strauss,  at  least  40  Cc.  before  the  clinician  is 
justified  in  making  a  diagnosis  of  hypersecretion.  There  is 
somewhat  of  an  increase  in  the  degree  of  acidity;  erythro- 
dextrin and  achroodextrin  are  absent.  There  must  be  no 
food  remnants,  sarcinse,  or  yeast  cells.  In  gastric  dilatation 
which  may  result  from  spasm  of  the  pylorus  we  find  fer- 
mentation products,  yeast  cells,  and  sarcinse. 

4.  Acute  Gastritis. — Examination  of  the  gastric  contents  in 
this  condition  reveals  a  diminished  total  acidity  with  little 
or  no  free  hydrochloric  acid.  The  total  acidity  is  always 
below  40  degrees.  Much  mucus  and  undigested  food  is 
apt  to  be  found.  The  hydrochloric  acid  secretion  is  either 
very  much  diminished  or  entirely  absent. 

5.  Chronic  Gastritis. — Examination  of  the  stomach  con- 
tents in  this  condition  reveals  nmch  mucus  usually  mixed 
with  the  food,  which  shows  little  signs  of  digestion.  The 
quantity  varies  from  100  to  200  Cc.  Free  hydrochloric 
acid  is  diminished  or  absent,  and  the  gastric  ferments 
are  very  much  reduced.  The  total  acidity  is  below  40 
degrees.  Pepsinogen  and  rennin  zymogen  aie  always 
present.  Erythrodextrin  is  found  in  small  (juantities, 
and   achroodextrin    in    abundance.     The    i)resence   of   epi- 


CHANGES  IN  GASTRIC  SECRETION  73 

thelial  cells  and  leucocytes  is  detected  by  microscopic 
examination.  The  finding  of  large  amounts  of  mucus  in 
which  are  mingled  leucocytes  and  epithelial  cells  is  charac- 
teristic of  chronic  gastritis. 

6.  Achylia  Gastrica. — For  a  diagnosis  of  this  condition 
the  Ewald-Boas  test  breakfast  may  be  used  with  advantage. 
Examination  of  the  stomach  contents  shows  very  little 
change  in  the  ingested  food.  There  is  usually  a  small  amount 
of  fluid  present.  The  food  has  a  characteristic  appearance, 
showing  complete  lack  of  digestion.  There  is  no  free  hydro- 
chloric acid,  and  the  total  acidity  is  very  low,  1  to  6  degrees. 
The  gastric  ferments  are  either  very  much  diminished  or 
entirely  absent.  There  is  no  evidence  of  decomposition, 
no  odor,  and  no  mucus.  Erythrodextrin  is  absent.  Lactic 
acid  is  present  in  small  quantities  if  at  all. 

7.  Motor  Insufficiency  (Atony  and  Dilatation). — When  motor 
insufficiency  is  suspected,  a  tablespoonful  of  currants  should 
be  given  to  the  patient  in  the  evening,  to  be  followed 
by  a  test  breakfast  the  next  morning.  Einhorn  gives 
boiled  rice  instead  of  currants.  If  either  the  currants  or  the 
boiled  rice,  as  the  case  may  be,  be  found  in  the  fasting 
stomach  or  removed  with  the  test  breakfast,  a  diagnosis 
of  motor  insufficiency  is  made.  The  volume  of  the  gastric 
contents  is  generally  increased,  and,  as  a  rule,  more  than 
180  Cc.  is  found  after  the  test  breakfast.  If  after  a  full 
meal  in  the  evening  visible  food  remnants  are  found 
in  the  fasting  stomach  in  the  morning,  in  all  proba- 
bility the  condition  is  one  of  motor  insufficiency  of  the 
second  degree,  inasmuch  as  food  remnants  are  never  found 
in  simple  atony.  The  quantity  of  residue  found  in  the 
stomach  is  an  indication  of  the  motor  power  of  that  organ. 
In  aggravated  cases  of  motor  insufficiency  food  residues 
are  often  found  in  the  stomach  seven  hours  after  the  admin- 
istration of  a  test  meal,  when  the  stomach  under  normal 
conditions  would  be  empty.  In  severe  cases  the  quantity 
of  urine  excreted  during  the  twenty-four  hours  is  markedly 
diminished,  whereas  in  atony  or  motor  insufficiency  of  the 
first  degree  it  is  normal.    Owing  to  the  variabihty  in  the 


74  EXAMINATION  OF  THE  STOMACH  CONTENTS 

gastric  secretion  in  motor  insufficiency,  chemical  analysis 
affords  but  little  aid  to  the  diagnosis.  In  the  initial  stages 
of  gastric  atony  the  secreting  glands  produce  an  excessive 
amount  of  gastric  juice,  followed  by  a  diminution  due  to 
fatigue  of  the  glands.  At  first  the  hydrochloric  acid  may 
show  a  marked  increase,  or  it  may  remain  normal  for  a 
long  time.  Some  cases  of  motor  insufficiency  may,  upon 
examination  of  the  gastric  contents,  show  subacidity  or 
anacidity. 

8.  Pyloric  Stenosis. — In  this  condition  there  is  always 
retention  of  food  in  the  stomach.  Should  the  patient  par- 
take of  mixed  diet  in  the  evening,  and  the  gastric  contents 
be  removed  the  following  morning,  the  various  food  resi- 
dues can  be  recognized  macroscopically.  Dilatation  of  the 
stomach  always  accompanies  pyloric  stenosis.  When  the 
obstruction  is  of  benign  origin,  free  hydrochloric  acid  is 
usually  present,  whereas  it  is  usually  absent  in  cases  of 
malignant  origin.  Lactic  acid,  which  is  absent  in  cases 
of  benign  obstruction,  is  usually  found  in  mahgnant  obstruc- 
tion. In  malignancy  there  is  a  marked  decrease  in  total 
acidity  of  the  gastric  juice,  while  in  benign  obstruction  the 
acidity  may  be  increased  several  degrees.  Rennin,  always 
found  in  cases  of  benign  stenosis  of  the  pylorus,  is  fre- 
quently absent  in  malignant  obstruction.  The  odor  of  the 
gastric  contents  is  more  marked  and  fetid  in  malignant 
than  in  benign  stenosis.  In  the  former  condition  the  Boas- 
Oppler  bacillus  is  found,  while  in  benign  cases  it  is  absent. 
Sarcinse,  which  may  be  present  in  benign  stenosis,  are  usually 
absent  in  the  malignant  form.  In  pjdoric  stenosis  the 
gastric  contents,  if  withdrawn  and  allowed  to  stand  in  a 
glass,  will  separate  out  so  as  to  form  three  layers  or 
strata.  The  upper  layer  is  frothy,  due  to  decomposition; 
the  middle  layer  is  clear  or  slightly  cloudy;  the  lowest  layer 
is  semisolid. 

9.  Pyloric  Insufficiency. — The  diagnosis  of  this  condition 
is  confirmed  when  the  stomach  is  found  empty  after  the 
administration  of  the  Ewald-Boas  test  breakfast.  The 
degree  of  pyloric  insufficiency  is  ascertained  by  administering 


CHANGES  IN  GASTRIC  SECRETION  75 

test  meals  on  successive  days  and  removing  the  contents 
at  stated  intervals,  such  as  three-quarters  of  an  hour,  half 
an  hour,  and  fifteen  minutes,  after  the  ingestion  of  the  test 
meal.  Chemical  analysis  of  the  gastric  secretion  may  reveal 
the  presence  of  hydrochloric  acid,  pepsin,  and  rennin,  or 
these  may  be  absent.  The  ready  passage  of  air  from  the 
stomach  tube  through  the  stomach  into  the  duodenum 
points  to  insufficiency  of  the  pylorus. 

10.  Gastric  Ulcer. — The  clinical  symptoms  are  of  greater 
importance  than  examination  of  gastric  contents  in  the 
diagnosis  of  this  condition.  The  use  of  the  stomach  tube 
is  obviously  inadvisable  when  ulceration  is  suspected.  The 
vomitus  consists  of  well-digested  food,  which  may  or  may 
not  be  free  from  blood.  If  blood  be  present,  it  will  be 
either  of  a  fresh  red  color  or  dark.  The  total  acidity,  of 
which  free  hydrochloric  acid  constitutes  the  major  portion, 
is  usually  increased;  at  times  it  may  be  three  times  the 
normal — up  to  180  degrees.  The  test  for  occult  blood  will 
usually  reveal  it  in  the  feces. 

11.  Erosions  of  the  Stomach.- — In  this  condition  examination 
of  the  returned  water  from  gastric  lavage  reveals  small 
fragments  of  mucous  membrane  which,  under  the  micro- 
scope, show  blood  corpuscles  and  gastric  glands  the  form 
of  which  is  apt  to  be  well  preserved  and  distinct.  These 
fragments  of  gastric  mucosa  are  constantly  found  when  the 
patient's  stomach  is  washed  out  in  the  fasting  condition 
(Einhorn).  In  perhaps  the  majority  of  cases  of  gastric 
erosion  there  is  a  decrease  in  the  hydrochloric  acid  secretion. 
On  rare  occasions,  on  the  other  hand,  hyperacidity  may 
exist.    Mucus  is  present  in  greater  or  less  quantity. 

12.  Gastric  Cancer. — In  this  condition  the  examination 
of  gastric  contents  yields  certain  results  suggestive  of  the 
disease.  Among  these  is  the  absence  of  free  hydrochloric 
acid.  This  is  among  the  early  symptoms,  and  is  presumed 
to  be  present  in  about  90  per  cent,  of  all  cases.  It  is  also 
found  in  achylia  gastrica  and  in  advanced  stages  of  chronic 
gastritis.  Free  hydrochloric  acid  may,  however,  be  present 
in  normal  or  more  than  normal  amounts  when  the  cancer 


76  EXAMINATION  OF  THE  STOMACH  CONTENTS 

is  small  and  ulcerous  and  occupies  the  pyloric  region.  The 
acidity  in  gastric  cancer  is  subject  to  marked  variations 
from  day  to  day.  The  total  acidity,  as  well  as  the  amount 
of  free  hydrochloric  acid,  is  diminished. 

The  presence  of  lactic  acid,  increased  in  amount,  is  also 
suggestive  of  cancer  of  the  stomach;  90  per  cent,  of 
cases  show  lactic  acid  present  and  free  hydrochloric  acid 
absent.  In  testing  for  lactic  acid  the  contents  of  the  fasting 
stomach  should  be  examined  in  the  morning,  after  thorough 
gastric  lavage  the  night  before.  In  cancer  cases  this  exami- 
nation will  show  very  slight  digestion  of  proteins,  with  fairly 
good  digestion  of  carbohydrates.  The  finding  of  amino-acids 
in  the  gastric  contents  is  important.  The  microscope  may 
show  fragments  of  the  neoplasm,  such  as  cellular  masses, 
embedded  in  blood — a  very  definite  diagnostic  sign.  The 
Boas-Oppler  bacillus  is  said  to  occur  in  75  to  85  per  cent,  of 
carcinomatous  patients,  and  is  rarely  found  in  any  other. 
The  test  for  occult  blood  in  the  feces  is  usually  positive. 


CHAPTER    III 

DIET   IN   GASTRIC   DISEASES 

For  practical  purposes  food  may  be  defined  as  any  sub- 
stance which,  when  taken  into  the  body,  assists  in  its 
nutrition  and  maintenance,  or  replaces  its  waste  and  losses. 
Food  has  two  main  functions — namely,  the  provision  for 
growth  and  repair  of  the  animal  body,  and  as  a  source  of 
potential  energy  to  be  converted  into  heat  and  work.  Sub- 
stances which  may  not  serve  either  of  these  functions  may 
yet  fulfil  a  useful  place  in  a  dietary.  Such  articles  as  tea, 
coffee,  and  meat  extractives,  while  they  cannot  be  properly 
classed  as  foods,  are  important,  nevertheless,  in  the  consider- 
ation of  dietetics. 

Composition  of  Foods. — In  order  to  know  the  food  value  of 
any  animal  or  vegetable  product  it  is  necessary  to  know  its 
composition — the  amount  of  water,  salts,  proteins,  fats,  and 
carbohydrates  it  contains.  The  accompanying  table  (p.  78), 
compiled  by  Munk,^  gives  the  average  composition  of  some 
of  the  most  common  articles  of  diet.  It  will  be  seen  from 
the  table  that  the  carbohydrate  content  of  meats  is  small 
compared  with  the  protein  and  fat;  but  even  meats  show 
marked  variation  in  regard  to  the  protein  and  fat.  Vege- 
table foods,  on  the  other  hand,  are  rich  in  carbohydrates  and 
contain  comparatively  small  amounts  of  protein  and  fat. 
While  carbohydrates  predominate  in  vegetable  foods,  legu- 
ininous  products  show  a  percentage  of  protein  which  some- 
times exceeds  that  found  in  meat. 

Important  as  is  a  knowledge  of  the  chemical  composition 
of  foods,  we  should  not  lose  sight  of  the  fact  that  their 
nutritive  value  is  not  dependent  upon  their  chemical  com- 
position alone,  but  upon  their  digestibihty  and  absorbability 
as  well. 

^  Howell's  Physiology. 


78                                 DIET  IN 

GASTR 

IC  DISE^ 

iSES 

Composition 

OF  Foods 

Carbohydrates. 

In  100  parts. 

Water. 

Protein. 

Fat. 

Digestible. 

Cellulose. 

Ash. 

Meat     .... 

76.7 

20.8 

1  5 

0.3 

1.3 

Eggs     .... 

73.7 

12.6 

12.1 

1.1 

Cheese 

36-60 

25-33 

7-20 

3-7 

3-4 

Cow's  milk 

87.7 

3.4 

3.2 

4.8 

0.7 

Human  milk    . 

89.7 

2.0 

3.1 

5.0 

0.2 

Wheat  flour     . 

13.3 

10.2 

0.9 

74.8 

0.3 

0.5 

Wheat  bread  . 

35.6 

7.1 

0.2 

55.5 

0.3 

1.1 

Rye  flour   . 

13.7 

11.5 

2.1 

69.7 

1.6 

1.4 

Rye  bread 

42.3 

6.1 

0.4 

49.2 

0.5 

1.5 

Rice      .... 

13.1 

7.0 

0.9 

77.4 

0.6 

1.0 

Corn     .... 

13.1 

9.9 

4.6 

68.4 

2.5 

1.5 

Macaroni   . 

10.1 

9.0 

0.3 

79.0 

0.3 

0.5 

Peas,  beans,  lentils 

12-15 

23-26 

U-2 

49-54 

4-7 

2-3 

Potatoes     . 

75.5 

2.0 

0.2 

20.6 

0.7 

1.0 

Carrots 

87.1 

1.0 

0.2 

9.3 

1.4 

0.9 

Cabbages  . 

90.0 

2-3 

0.5 

4-6 

1-2 

1.3 

Mushrooms     . 

73-91 

4-8 

0.5 

3-12 

1-5 

1.2 

Fruit     .... 

84.0 

0.5 

10.0 

4.0 

0.5 

Food  as  it  is  ingested  differs  widely  in  its  composition 
from  the  nutrient  material  ultimately  required  for  the  repair 
of  waste  and  the  sustenance  of  the  body.  Before  it  can  be 
utilized  in  the  animal  economy  it  must  undergo  a  more  or 
less  complex  process,  designated  by  the  term  ''digestion," 
which  means  alteration  in  the  alimentary  tract  by  certain 
unorganized  ferments  (enzymes). 

Diet  plays  the  most  important  part  in  the  treatment  of 
diseases  of  the  stomach.  In  prescribing  diet  for  patients 
with  gastric  disease  of  any  kind,  great  care  should  be  exer- 
cised to  avoid  that  which  will  tend  to  irritate  the  affected 
stomach.  A  properly  selected  diet  usually  fulfils  a  number 
of  indications,  such  as  diminution  of,  the  production  of 
mucus,  or  increased  or  decreased  secretion  of  acid;  it  will 
obviate  the  danger  of  overburdening  the  muscular  coats, 
and  in  this  way  fortify  the  tone  of  the  stomach.  Reduction 
of  abnormal  fermentative  processes  may  be  accomplished 
by  a  properly  selected  diet. 

The  progress  made  in  the  treatment  of  diseases  of  the 
stomach  and  intestine  has  been  due  mainly  to  more  accu- 
rate knowledge  of  the  chemical  composition  of  food  and  of 


HEAT  VALUE  OF  FOODS  79 

the  changes  that  take  place  within  the  human  organism. 
Simple  methods  of  examining  the  stomach  contents  have 
disposed  physicians  to  make  greater  use  of  the  stomach 
tube  to  ascertain  qualitative  and  quantitative  deviations 
from  the  normal  in  gastric  digestion.  The  results  obtained 
by  accurate  analysis  render  the  prescribing  of  proper  diet  a 
comparatively^  easy  matter.  We  now  have  tables  showing 
precisely  the  length  of  time  food  remains  in  the  stomach, 
and  also  the  time  required  for  digestion.  Since  we  are  able 
to  remove  and  examine  the  stomach  contents  at  will,  we 
can  adapt  the  treatment  to  the  disease  much  better  than 
would  be  possible  if  dietetic  directions  had  to  be  given  with- 
out the  laboratory  aids. 

Heat  Value  of  Foods. — The  heat  value  of  the  various  food- 
stuffs has  been  determined  by  experiment,  and  the  result 
is  expressed  in  calories.  A  calorie  is  the  amount  of  heat  re- 
quired to  raise  the  temperature  of  one  kilogramme  of  water 
1°  Centigrade,  or  approximately  the  amount  required  to  raise 
the  temperature  of  one  pound  of  water  4°  Fahrenheit.  Ex- 
pressed in  mechanical  force,  a  calorie  would  raise  a  ton 
about  1.54  feet;  in  other  words,  it  is  equal  to  1.54  foot-tons. 
According  to  Atwater,  one  gramme  of  protein  furnishes  4 
calories;  one  pound,  1820;  one  gramme  of  fat  furnishes  9, 
and  one  pound  4004  calories;  one  gramme  of  carbohydrate 
furnishes  4,  and  one  pound  1820  calories.  The  calorific  value 
of  foods  must  be  borne  in  mind.  Patients  suffering  from 
gastric  disease  are  usually  placed  on  a  too  restricted  diet; 
the  number  of  calorific  units  is  too  small,  and  as  a  con- 
sequence the  patients  rapidly  lose  flesh.  It  is  absolutely 
necessary  in  all  cases  of  chronic  disease  of  the  stomach  to 
see  that  the  patient  obtains  the  required  number  of  calories 
every  twenty-four  hours. 

Fat  in  the  form  of  butter  is  one  of  the  best  foods  for 
developing  heat  without  injuring  the  stomach.  In  all  chronic 
diseases  of  the  stomach,  fat  agrees  well.  In  many  diseases 
of  the  digestive  organs  the  most  satisfactory  progress  has 
been  made  by  adding  great  quantities  of  fat  to  the  dietary. 
Investigations  in  metabolism  have  verified  this. 


80  DIET  IN  GASTRIC  DISEASES 

Dietary  Regulations  and  Lists. — The  experience  which  the 
patient  has  gained  in  reference  to  his  own  diet  should  be 
taken  into  consideration  when  prescribing  a  diet  for  him.  The 
postulate  of  Boas,  ''throw  away  the  printed  dietary  lists,"  is 
based  upon  the  desire  to  escape  from  monotonous  routine 
in  the  treatment  of  patients  suffering  from  gastric  disorders, 
inasmuch  as  it  is  not  possible  to  satisfy  the  subjective 
sensations  of  the  patients  by  means  of  fixed  rules.  Patients 
frequently  maintain  that  they  are  unable  to  digest  certain 
articles  of  food.  Such  assertions  vary,  but  correspond, 
however,  to  the  peculiar  nature  of  gastric  digestion,  inas- 
much as  the  assimilability  of  certain  articles  of  food 
differs  markedly  in  different  patients.  The  habits  of  the 
patient  are  likewise  to  be  taken  into  consideration.  The 
preference  for  or  objection  to  certain  foods,  the  desire  for 
change  or  for  certain  modes  of  preparation,  the  behavior 
of  the  patient  as  to  appetite  and  the  sensation  of  hunger^ 
are  all  of  great  importance  when  considering  the  selection 
of  a  menu.  Appetite  and  hunger  are  trustworthy  guides 
to  the  healthy  man  for  the  food  requirements  of  the 
body.  In  health,  as  much  food  as  the  normal  appetite 
calls  for  is  generally  eaten;  this  corresponds,  as  a  rule,  to 
the  quantity  which  can  be  assimilated  and  by  which  the 
body  weight  is  kept  fairly  constant  for  a  considerable  space 
of  time.  In  patients  with  disease  of  the  stomach  the 
appetite  and  the  sensation  of  hunger  are,  as  a  rule,  not  a 
trustworthy  guide  for  the  quantity  of  food  required;  in 
most  cases  both  are  below  normal. 

When  this  is  the  case  the  diet  must  be  regulated  in  such 
a  manner  that  nutrition  does  not  suffer  on  account  of  the 
deficient  appetite.  To  diet  does  not  mean  to  starve.  It 
is  also  of  great  importance  to  search  for  the  causes  of  the 
anorexia.  These  may  consist  of  organic  disease  of  the 
stomach,  or  they  may  be  of  a  purely  nervous  nature.  The 
diminished  appetite  may  have  been  induced  artificially  by  a 
dietary  plan  which  the  patient  himself  had  determined  upon 
before  seeking  medical  advice.  The  statements  of  patients 
regarding  the   digestibility   and   general   effects  of  certain 


DIETARY  REGULATIONS  AND  LISTS  81 

articles  of  food  must  not  be  accepted  unreservedly  as  a  guide 
to  treatment. 

Digestibility  is  a  term  which  is  frequently  misunderstood 
and  misapplied.  Digestibility  does  not  involve  the  question 
of  distress,  nor  the  question  of  the  food  containing  suffi- 
cient calories;  for  not  every  food  which  is  well  digested  is 
well  borne,  and  not  every  food  which  is  well  borne  is  digested 
well  and  properly  assimilated.  The  amount  of  digestive 
effort  required  varies  with  different  articles  of  diet.  A 
person  whose  gastro-intestinal  tract  is  normal  can  digest 
and  assimilate  without  discomfort  any  kind  of  reasonable 
food  which  he  can  eat. 

The  term  "digestible"  signifies,  however,  something  quite 
different  in  gastric  disease.  Riegel  defines  a  diet  as  easily 
digestible  which  does  not  make  great  demand  on  the  secre- 
tory and  motor  functions  of  the  stomach,  and  which  is 
easily  absorbed  without  producing  subjective  discomforts. 
This  definition  also  includes  assimilabihty,  or  good  effect 
after  absorption.  Wegele  claims  that  a  food  is  easily  diges- 
tible when  it  fulfils  the  following  conditions:  (1)  It  must 
offer  but  httle  resistance  to  the  digestive  juices;  that  is, 
it  must  be  easily  soluble.  (2)  It  must  not  impede  the 
peristaltic  movements,  nor,  on  the  other  hand,  should  it 
accelerate  the  movements  of  the  stomach  too  much.  (3) 
It  must  not  seriously  irritate  the  digestive  organs  chemi- 
cally or  mechanically.  (4)  It  must  be  easy  of  absorption, 
either  from  the  stomach  or  from  the  intestine.  Schmidt 
describes  those  foods  as  easily  digestible  which  require  the 
least  digestive  effort  in  the  presence  of  gastric  diseases.  It 
has  become  an  estabhshed  practice  to  calculate  the  degree 
of  digestibility  from  the  length  of  time  the  foods  remain  in 
the  stomach.  Penzoldt  has  ascertained  this  relation  in 
health  (Table  I),  and  with  this  in  view  has  arranged  four 
different  forms  of  diet,  proceeding  from  light  to  heavy 
(Table  11) ;  these  agree  fairly  well  with  the  four  forms  of 
diet  proposed  by  Leube,  which  also  take  into  consideration 
the  time  the  foods  remain  in  the  stomach.  Both  these 
dietary  lists  are  constructed  with  a  view  to  affording  an 
6 


82  DIET  IN  GASTRIC  DISEASES 

easily  digestible  menu  for  patients  suffering  from  diseases 
of  the  stomach. 

Table  I 
Leaves  the  stomach  in : 

One  to  two  hoiirs: 

100  to  200  Gm.  Water,  pure. 

200  Gm.  Water  containing '002. 

200  Gm.  Tea,  pure. 

200  Gm.  Coffee,  pure. 

200  Gm.  Cocoa,  pure. 

200  Gm.  Beer. 

200  Gm.  Light  wines. 

100  to  200  Gm.  Milk,  boiled. 

200  Gm.  Bouillon,  pure. 

100  Gm.  Eggs,  soft. 

Two  to  three  hours : 

200  Gm.  CofTee  and  cream. 

200  Gm.  Cocoa  and  milk. 

200  Gm.  Malaga. 

200  Gm.  Wine. 

300  to  500  Gm.  Water. 

300  to  500  Gm.  Beer. 

300  to  500  Gm.  Milk,  boiled. 

100  Gm.  Eggs,  raw,  or  scrambled,  hard-boiled,  or  omelet. 

100  Gm.  Beef  sausage. 

250  Gm.  Calf's  brain,  boiled. 

72  Gm.  Oysters,  raw. 

200  Gm.  Carp,  boiled. 

200  Gm.  Pike,  boiled. 

200  Gm.  Cod,  boiled. 

200  Gm.  Sole,  boiled. 

150  Gm.  Cauliflower,  boiled. 

150  Gm.  CauHflower  salad. 

1.50  Gm.  Asparagus,  boiled. 

150  Gm.  Potatoes,  salt  potatoes. 

1.50  Gm.  Potatoes,  mashed. 

150  Gm.  Cherry  jam. 

150  Gm.  Cherries,  raw. 

70  Gm.  White  bread,  fresh  or  stale,  dry  or  with  tea. 

70  Gm.  Rusk,  new  or  stale,  dry  or  with  tea. 

70  Gm.  Cracknel  (pretzel). 

50  Gm.  Albert  biscuits. 


DIETARY  REGULATIONS  AND  LISTS  83 

Table  I  (Continued) 
Leaves  the  stomach  in : 

Three  to  four  hours: 

230  Gm.  Chicken,  young,  boiled. 

230  Gm.  Partridge,  roast. 

200  to  260  Gm.  Squab,  boiled. 

195  Gm.  Squab,  roast. 

250  Gm.  Beef,  raw  or  boiled,  lean. 

250  Gm.  Calf's  feet,  boiled. 

160  Gm.  Ham,  raw  or  boiled. 

100  Gm.  Roast  veal,  warm  or  cold,  lean. 

100  Gm.  Beefsteak,  fried,  cold  or  warm. 

100  Gm.  Beefsteak,  raw,  minced. 

100  Gm.  Sirloin  steak. 

200  Gm.  Salmon,  boiled. 

72  Gm.  Caviar,  salted. 

200  Gm.  Lampreys  in  vinegar. 

200  Gm.  Smoked  herring. 

150  Gm.  Rye  bread. 

150  Gm.  Graham  bread. 

150  Gm.  White  bread. 

100  to  150  Gm.  Albert  biscuits, 

150  Gm.  Potatoes. 

150  Gm.  Rice,  boiled. 

150  Gm.  Kohlrabi,  boiled. 

150  Gm.  Beet,  boiled. 

150  Gm.  Spinach,  boiled. 

150  Gm.  Cucumber  salad. 

150  Gm.  Radishes,  raw. 

150  Gm.  Apples. 

Four  to  five  hours : 

210  Gm.  Squab,  fried. 

350  Gm.  Fillet  of  beef. 

250  Gm.  Beefsteak,  fried. 

250  Gm.  Ox  tongue,  smoked. 

100  Gm.  Smoked  meat,  sliced. 

250  Gm.  Hare,  roast. 

240  Gm.  Partridge,  fried. 

250  Gm.  Goose,  fried. 

280  Gm.  Duck,  fried. 

200  Gm.  Herring  in  salt. 

150  Gm.  Lentils,  puree. 

200  Gm.  Peas,  puree. 

150  Gm.  Beans,  boiled. 


84 


DIET  IN  GASTRIC  DISEASES 


Table  II 
1.  Diet  (about  ten  days) 


Foods  or  bev- 

Largest quantity 

Method  of  prepara- 

General character. 

How  to  be  taken. 

erages. 

at  one  time. 

tion. 

Meat 

250  Gm. 

From  beef. 

Lean,  unsalted  or 

Slowly. 

broth. 

shghtly  salted. 

Cow's  milk. 

250  Gm. 

Well  boiled,  or 

Pure  milk,  or   ^ 

With  tea  if  de- 

sterilized. 

hme  water. 

sired. 

Eggs. 

One  to  two. 

Soft,  just  warm,  or 
raw. 

Fresh. 

If     raw,     stir 
into  warm 
(not  boiling) 
broth. 

Meat     sol. 

30  to  40  Gm. 

To  have   merely 

Teaspoonful 

(Leube 

a  slight  odor  of 

doses,  or 

and  Ros- 

bouillon. 

stirred  in 

enthal)  . 

meat  broth. 

Biscuits 

Six. 

Without  sugar. 

Without  sugar. 

Hard.     Masti- 

(Albert 

cate  well 

biscuits) . 

and     insali- 
vate. 

Water. 

i  liter. 

Ordinary,  or  nat- 
ural CO2  water 
weak  (Seltzer). 

Not  too  cold. 

2.  Diet  (about  ten  days) 


Foods  or  bev- 

Largest quantity 

Method  of  prepara- 

General character. 

How  to  be  taken 

erages. 

at  one  time. 

tion. 

Calf's 

100  Gm. 

Boiled. 

Without   con- 

Best in  broth. 

brain. 

nective   tissue 
of  any  kind. 

Calf's 

100  Gm. 

Boiled. 

Without  con- 

Best in  broth. 

thymus 

nective  tissue 

(sweet  - 
bread). 
Pigeon. 

of  any  kind. 

One. 

Boiled. 

Young,   tender, 

Best  in  broth. 

without    ten- 

dons, skin,  etc. 

Chicken. 

One,  medium 
size. 

Boiled. 

Young,  tender, 
without   tcn- 
ilons,  skin,  etc. 

Best  in  l^roth. 

Raw  beef. 

100  Gm. 

Minced,    chipped, 
or  scraped,  with 
little  salt. 

Fillet. 

To  be  eaten 
with 
crackers. 

Beef  sau- 

100 Gm. 

No  additions. 

Slightly  smoked. 

To   be   eaten 

sage,  raw 

with 
crackers. 

Tapioca. 

30  Gm. 

With   milk   as 
pudding. 

DIETARY  REGULATIONS  AND  LISTS 


85 


3.  Diet  (about  eight  days) 


4.  Diet  (about  eight  to  fourteen  days) 


Foods  or  bev- 
erages. 

Largest  quantity 
at  one  time. 

Method  of  prepara- 
tion. 

General  character. 

How  to  be  taken. 

Venison. 

100  Gm. 

Roast. 

Back,    saddle, 
hung,  not  high 
flavor. 

Partridge. 

One. 

Fried,    without 
bacon. 

Young,  tender. 

Roast  beef. 

100  Gm. 

Rare. 

Good  breed,  well  Warm  or  cold, 
pounded. 

Fillet. 

100  Gm. 

Rare. 

Good  breed,  well  Warm  or  cold, 
pounded. 

Veal. 

100  Gm. 

Roast. 

Saddle,  leg.            Warm  or  cold. 

Fish:  pike, 

100  Gm. 

Boiled  in  salt 

With  bones  care-: In  fish  sauce. 

sole,  carp, 

water  without 

fully  removed. 

trout. 

addition. 

Caviar. 

50  Gm. 

Raw. 

SUghtly  salted, 
Russian. 

Rice. 

50  Gm. 

Pudding,  soft. 

Boiled  soft. 

Asparagus. 

50  Gm. 

Boiled. 

Soft. 

Butter  sauce. 

Scrambled 

Two. 

With  fresh  butter, 

eggs. 

little  salt. 

Egg,  ome- 

Two. 

With  20  Gm. 

Well  risen  (Ught).  To  be  eaten  as 

let  or 

sugar. 

prepared. 

custards. 

Fruit. 

50  Gm. 

Fresh,    boiled    or 

Free  of  seeds  and 

stewed. 

skin. 

Claret. 

100  Gm. 

Light,    pure    Bor- 

Any good  claret  Slightly 

deaux. 

or  red  wine. 

warmed. 

86  DIET  IX  GASTRIC  DISEASES 


Table  III — Dietary  Lists  or  Leube 

1.  Beef  tea  (bouillon,  meat  solution),  milk,  soft  and  raw  eggs,  zwieback  or 

biscuits  without  either  sugar  or  fat;  plain  water  or  natural  mineral 
waters  poor  in  carbon  dioxide. 

2.  Boiled   calf's   brain,    sweetbreads,    chicken,    squab,     glutinous    soups, 

tapioca,  milk  pudding,  boiled  calf's  feet. 

3.  Minced  beefsteak  (loin),   minced   raw  ham,   mashed   potatoes,  white 

bread  (small  amounts) ;  small  quantities  of  coffee  or  tea  with  milk 
(or  trial  only). 

4.  Roast  chicken,  squab,  deer,  partridge  (hare,  rather  not),  roast  beef 

(rare),  roast  veal  (leg),  pike,  cod  (steamed),  macaroni,  bouillon-rice 
(later  verj^  light  pudding),  wine  in  small  portions. 

The  following  table,  taken  from  Schmidt,  shows  the  per- 
centage of  nutritive  material  in  each  of  the  articles  named 
that  is  lost  in  the  processes  of  chgestion  and  assimilation, 
not  being  made  available  to  the  tissues: 

Table  IV  ^    , 

Carbo- 

Protein.  Fat.         hydrates. 

Meat 3  5 

Fish  (cod) 3 

Eggs 3  5 

Milk 1  to  7  3  to  5 

WTiite  bread  (wheat) 22  ...         1  to  3 

Rye  bread '.      .      .  32  ...  11 

Macaroni 17  6  1 

Rice 20  7  1 

Peas  (puree) 17  ...  4 

Potatoes  (whole) 32  4  8 

Potatoes  (mashed) 20  ...  4 

Cabbage  (green) 18  6  15 

Carrots  (yellow) 39  6  18 

Experience  teaches  that  emaciation  and  loss  of  strength 
must  be  referred,  in  the  majority  of  cases  of  gastric  disease, 
to  insufficient  nutrition.  It  is,  therefore,  imjiortant  to  know 
the  quantity  of  food  absolutely  needed  by  the  body.  In 
health  the  requirements  for  the  average  adult  are  100 
grammes  of  protein,  50  grammes  of  fat,  and  450  grammes 
of  carbohydrate,  daily.  Expressed  in  calories  the  number 
is  2720.  Individual  articles  of  diet  may  be  substituted  one 
for  another  in  proportion  to  their  heat  values.   Obviously  the 


MEAT  87 

constitution  and  the  appetite  of  the  patient  offer  certain 
limits  which  must  be  respected.  If  one  or  more  ordinarily 
desirable  articles  of  diet  are  not  acceptable  to  the  patient 
we  mSLY  substitute  others,  so  long  as  we  supply  the  required 
number  of  heat  units.  When  considering  this  question  it  is 
important  to  remember  that  a  person  at  rest  requires  fewer 
calories  than  one  at  work.  In  health  the  requirements  per 
kilo  body  weight  per  day,  at  rest,  are  30  to  35  calories;  at 
hght  labor,  35  to  40  calories;  and  at  average  labor,  40  to  45 
calories.  In  the  treatment  of  severe  chronic  gastric  disease 
the  patients  should  be  confined  to  bed  in  order  to  economize 
the  heat  units  contained  in  the  comparatively  small  amount 
of  food  they  are  able  to  take. 

Meat. — Much  discussion  has  taken  place  regarding  the 
respective  merits  of  light  and  dark  meat.  The  significance 
of  the  distinction  has  frequently  been  exaggerated,  but 
certain  differences  should  not  be  disregarded.  White  meat 
(veal,  fowl)  possesses  a  shorter,  softer,  and  more  tender 
fibre,  and  differs  from  dark  meat,  such  as  beef  and  mutton, 
by  its  smaller  proportion  of  extractives;  this  difference  is 
considerable.  The  fat  of  dark  meat  is  with  difficulty  dis- 
solved, and  therefore  offers  resistance  to  the  penetration  of 
the  digestive  juices.  Meat  may  be  defined  as  the  muscle 
of  an  animal  together  with  the  conjoined  connective-tissue 
substances,  such  as  tendons,  ligaments,  bones,  and  cartilage. 
The  internal  organs  of  the  animal,  so  far  as  they  are  edible, 
namely,  kidneys,  spleen,  liver,  sweetbread,  brain,  and  intes- 
tine, as  well  as  sea-foods,  such  as  fish,  lobster,  and  clam,  are 
also  included  under  the  term  "meat."  The  average  compo- 
sition of  meat  is:  Protein,  20  to  25  per  cent.;  fat,  gelatinous 
substances,  glycogen,  and  extractives  (kreatinin,  xanthin). 
The  meat  of  animals  recently  killed  should  be  permitted  to 
hang  for  some  time  before  it  is  eaten.  \^Tiile  meat  is  hang- 
ing, lactic  acid  is  produced  which  loosens  the  connective 
tissue  between  the  muscle  fibres,  thereby  softening  it  and 
rendering  it  more  easily  digestible.  Game  should  hang  for  a 
time  to  permit  of  this  softening  process,  especially  for  pa- 
tients with  gastric  troubles;  but  it  should  not  be  allowed  to 


88  DIET  IN  GASTRIC  DISEASES 

decompose  so  far  as  to  become  '^gamey, "  for  then  it  is  likely 
to  arouse  the  aversion  of  the  patient ;  or,  if  eaten,  to  increase 
the  digestive  disturbances  by  introducing  into  the  system 
the  products  of  decomposition.  Old  animals  naturally  yield 
tougher  meat  than  young. 

The  preparation  of  meat  is  important.  Raw  meat  ought 
to  be  avoided  by  patients  with  gastric  disease,  though  it  is 
more  easily  digested  in  health  than  is  cooked  meat.  The 
digestion  of  raw  meat  takes  place  both  in  the  stomach  and 
in  the  small  intestine;  the  coarse  connective  tissue  is  digested 
by  the  stomach,  the  muscle  fibre  by  the  small  intestine.  The 
stomach  cannot,  however,  digest  raw  meat  when  the  secre- 
tion of  hydrochloric  acid  is  defective;  on  the  other  hand, 
when  there  is  too  much  hydrochloric  acid,  still  more  of  it  is 
produced  under  the  stimulus  of  raw  meat  in  the  stomach. 
The  dictum  of  Schmidt  to  strike  out  raw,  rare,  and  smoked 
meat  from  the  diet  of  gastric  patients  is,  therefore,  a  reason- 
able one.  Smoked  and  canned  meats  behave  similarly  toward 
hydrochloric  acid.  Salted  or  canned  meats,  such  as  ham, 
ox  tongue,  smoked  or  corned  beef,  have  not  the  same  nutri- 
tive value  as  raw  meat  or  meat  prepared  in  any  other  way; 
during  the  pickling  process,  extractive  materials  and  phos- 
phates are  lost.  In  partaking  of  uncooked  meats  there  is 
always  a  possibility  of  infection  by  animal  parasites.  The 
custom  among  the  German  people  of  eating  raw  pork  is 
well  known.  Thousands  of  microscopists  are  employed  in 
Germany  to  prevent  trichinosis.  Stiles  finds  that  of  274 
cases  of  trichinosis  in  America  208  were  Germans.  The 
simplest  and  most  effective  method  of  preventing  the  dis- 
ease is  ignored.  The  cooking  of  the  meat  is  all  that  is 
necessary. 

The  majority  of  people  eat  more  meat  than  they  require. 
Meat  once  a  day  is  sufficient  for  a  person  not  engaged  in 
manual  labor,  or  for  one  who  does  not  take  nnich  vigoi-- 
ous  outdoor  exercise.  Many  gastric  troubles  owe  tluMr 
origin  to  the  consumption  of  food  which  causes  a  greater 
drain  on  the  gastric  juices  than  the  system  is  able  to  stand. 
Of  the  various  meats,  young  lean  beef  is,  as  a  rule,  the  most 


MEAT  89 

easily  digested.  The  white  meat  of  fowl  enjoys  a  special 
reputation,  to  which  most  clinicians  agree.  Yet  no  chemic 
differences  between  the  white  meat  and  dark  meat  have  yet 
been  shown. 

The  digestibihty  of  roasted,  boiled,  and  stewed  meats 
is  in  the  order  named.  It  may  be  increased  by  preliminary 
processes  such  as  beating,  grinding,  mincing,  and  scraping. 
Meats  poor  in  fat  are  generally  easily  digestible,  owing  to 
the  ready  accessibility  of  the  gastric  juice  to  the  muscle 
fibres.  The  following  varieties  are  permissible  for  gastric 
patients:  Beef,  veal,  lean  pork,  hare,  deer,  fowl,  squab, 
partridge,  pheasant,  and  all  kinds  of  lean  fish,  such  as 
trout,  pike,  codfish,  and  shad.  Because  of  their  high  per- 
centage of  fat,  goose,  herring,  and  salmon  should  be  avoided. 
Caviar,  though  rather  salty,  may  be  allowed,  as  may  also 
oysters  and  lobsters.  The  meat  of  the  lobster  is  not  so 
tough  and  difficult  to  digest  as  is  popularly  believed.  Sau- 
sage should  be  avoided  because  it  contains  about  40  per  cent, 
of  fat  and  a  great  deal  of  condiment. 

Foods  containing  gelatin  belong  to  the  group  of  meat 
nutrients.  They  are  of  great  importance  in  dietetics,  serv- 
ing as  protein  and  fat  sparers.  Gelatin  is  almost  entirely 
digested,  leaving  little  or  no  residue.  Tendons,  cartilage, 
ligaments,  connective  tissue,  and  bones  belong  to  this  class. 
Gelatin  is  present  in  larger  amount  in  the  broth  of  veal 
than  in  beef  broth.  Calf's  head  and  calf's  feet  are  rich  in 
gelatin.  Meat  jelly  is  a  popular  gelatinous  food  for  patients 
with  stomach  disease,  and  may  be  prepared,  according  to  Wiel, 
in  the  following  manner:  Four  calf's  feet,  one  kilogramme 
of  beef,  and  one  chicken  are  boiled  for  about  five  hours  in 
five  liters  of  water  with  15  grammes  of  common  salt.  Dur- 
ing the  last  hour  of  boiling  a  small  pike  is  added.  The  soup 
is  allowed  to  cool  over  night.  The  layer  of  fat  is  removed 
the  next  morning,  and  the  remaining  contents  of  the  dish 
are  taken  out  and  cleared.  This  brawn  is  then  gradually 
heated,  and,  after  it  has  liquefied,  well  beaten  white  of  eggs 
together  with  the  broken  egg  shells  is  added.  The  brawn  is 
gently  boiled  until  large  pieces  of  protein  are  precipitated 


90  DIET  IN  GASTRIC  DISEASES 

and  the  edges  of  the  brawn  appear  clear  as  wine.  It  is 
then  taken  from  the  fire  and  allowed  to  stand  until  com- 
pletely transparent.  It  is  then  filtered  through  a  previously 
moistened  napkin,  and  after  a  good  filtrate  has  been  ob- 
tained, 20  grammes  of  meat  extract  are  added,  and  the  jelly 
is  poured  into  forms  to  be  served  cold.  Meat  broth  is  not 
considered  a  food,  since  it  contains  only  small  quantities  of 
protein,  fat,  and  gelatin.  It  is,  however,  rich  in  extractives 
which  stimulate  the  secretion  of  hydrochloric  acid.  The  in- 
dications for  its  use  are,  therefore,  plain.  Bouillon  soups 
containing  eggs  or  flour  may  be  substituted  for  pure  meat 
broths. 

Pure  beef  tea  has  much  the  same  value  as  meat  broth.  It 
contains  rather  more  protein  and  glutinous  substances  than 
broth,  and  has  a  marked  effect  in  stimulating  the  appetite, 
favoring  the  secretion  of  gastric  juice  in  cases  of  acute  and 
chronic  affections  of  the  stomach.  Beef  tea  is  prepared  by 
taking  fresh  meat  free  from  fat  and  cutting  it  into  small 
pieces,  placing  it  in  a  bottle  without  water,  and  slowly  heat- 
ing it  on  the  water  bath;  after  steaming  for  twenty  minutes 
the  meat  juice  collects  as  a  turbid  yellowish  fluid. 

Eggs. — Eggs  are  to  be  taken,  as  such,  only  when  soft 
boiled,  the  white  barely  coagulated.  In  the  form  of  very 
light  egg  dishes,  or  stirred  up  in  soups,  they  make  a  very 
acceptable  addition  to  the  diet.  Hard-boiled  or  fried  eggs 
cannot  readily  be  reached  by  the  gastric  juice,  and  are  apt 
to  irritate  a  diseased  gastric  mucous  membrane,  unless  the 
hard  protein  is  first  very  finely  triturated.  Eggs  are  a 
concentrated  food  containing  protein  and  fat,  12  per  cent, 
of  each.  A  diet  consisting  solely  or  chiefly  of  eggs  should 
not  be  prescribed  for  patients  with  gastric  trouble,  since  even 
in  health  it  is  not  advisable  to  ingest  large  quantities  of 
protein  in  so  concentrated  a  form.  If  the  functional  de- 
rangement of  the  stomach  is  marked  by  subacidity  the 
peptonizing  power  is  of  course  deficient,  and  if  by  hyper- 
acidity the  secretion  of  acid  will  he  still  furtluM-  augmented 
by  the  ingestion  of  protein. 


MILK  91 

Fat. — A  diet  rich  in  fat  was  at  one  time  considered  dele- 
terious to  patients  with  gastric  disease.  At  present,  however, 
the  view  predominates  that  fat  is  a  food  which  is  very  well 
adapted  to  this  class  of  patients,  inasmuch  as  it  has  a  high 
calorific  value  in  proportion  to  its  volume.  We  know, 
moreover,  that  fat  hinders  the  secretion  of  gastric  juice, 
while  it  does  not  interfere  with  the  motility  of  the  stomach. 
Good  results  have  been  reported  after  the  adminis- 
tration of  fat  in  cases  of  disturbed  motor  activity  of  this 
organ.  The  fat  best  adapted  to  patients  with  gastric  dis- 
ease, as  has  been  said,  is  butter.  There  are  but  few  trust- 
worthy substitutes  for  good  butter.  Wegele  recommends 
'4ana, "  a  preparation  made  from  milk  of  almonds  and 
margarine.  Vegetable  (cocoanut)  butter  may  also  be  con- 
sidered. Of  other  fats  suitable  for  patients  with  stomach 
diseases,  we  have  cream,  olive  oil,  oil  of  sesame,  sweet  oil 
of  almond,  and  cod-liver  oil.  Because  of  its  disagreeable 
taste  cod-liver  oil  proves  repulsive  to  most  patients;  the 
taste  may  be  disguised  by  administering  the  oil  in  capsules. 

Milk. — Since  milk  contains  large  proportions  of  protein, 
fat,  and  carbohydrate,  it  is  an  excellent  article  of  diet. 
When  a  liquid  diet  alone  is  indicated,  milk  holds  first  place. 
It  must,  however,  be  borne  in  mind  that  milk  alone  is  unable 
to  supply  the  required  number  of  calories,  for  three  liters 
of  milk  contain  only  1800  calories.  Should  milk  prove 
repulsive  to  a  patient,  the  taste  may  be  disguised  by  com- 
bining it  with  other  articles  of  diet.  Milk  ought  to  be  given 
freshly  boiled,  as  it  is  then  more  easily  digested,  and  the 
germs  contained  in  it  are  destroyed  by  the  boiling  process. 
Milk  is  poorly  borne  by  many  patients,  and  for  various 
reasons.  Sometimes  the  reason  is  purely  subjective,  a  sort 
of  '^ phobia"  that  has  to  be  overcome  by  psychic  influence. 
Then,  again,  with  a  pure  milk  diet  a  large  quantity  is  neces- 
sary in  order  to  obtain  the  required  number  of  calories,  and 
this  large  volume  interferes  with  the  digestion  of  the  milk. 
The  volume  may  be  diminished  by  the  use  of  condensed 
milk.  The  stomach  contents  are  apt  to  become  excessively 
acid  when   great   quantities  of  milk   are   taken,  the  acid- 


92  DIET  IN  GASTRIC  DISEASES 

secreting  glands  being  stimulated  by  the  presence  of  the 
milk.  WTien  it  is  considered  advisable  to  prescribe  milk  in 
large  amounts,  the  hyperacidity  may  be  corrected  by  the  use 
of  alkaline  mineral  waters  in  small  amounts,  beginning  dur- 
ing the  second  hour  of  gastric  digestion.  The  addition  of 
lime  water  to  milk  will  often  aid  in  its  digestion  in  cases  in 
which  the  milk  would  not  otherwise  be  easily  borne.  ]^Iilk 
is  nearly  always  well  borne  if  it  does  not  remain  too  long  in 
the  stomach.  The  more  finely  the  casein  floccules  are  pre- 
cipitated the  less  discomfort  is  the  patient  likely  to  experi- 
ence from  a  milk  diet.  The  drinking  or  sipping  of  milk  in 
very  small  quantities  will  cause  a  fine  precipitation  of  casein 
in  the  stomach.  Part  of  the  pronounced  value  of  koumiss 
and  kefir  is  due  to  the  precipitation  of  casein  in  a  finely 
subdivided  condition.  Pegnin  (Dungern),  a  sterile  milk- 
sugar  rennet  ferment,  has  a  similar  action  in  producing  a 
finely  floccular  coagulation.  It  is  found  that  milk  causes 
much  discomfort  in  cases  of  stenosis  of  the  pylorus. 

Should  milk  as  such  not  be  permissible,  adA^antage  may  be 
taken  of  one  or  more  of  the  numerous  milk  preparations 
available.  Buttermilk  contains  less  fat  and  sugar  than  fresh 
milk,  but  the  small  percentage  of  lactic  acid  it  contains 
gives  it  an  agreeable  and  refreshing  taste ;  it  is  well  borne 
in  gastric  disease  and  is  particularly  useful  in  febrile  affec- 
tions of  the  stomach.  Sour  milk  prepared  in  the  following 
manner  has  a  somewhat  similar  action:  Two  tablespoonfuls 
of  sour  cream  are  mixed  with  half  a  liter  of  milk  which 
has  been  boiled  and  cooled.  The  mixture  should  be  well 
stirred,  and  allowed  to  remain  in  a  warm  place.  Two  table- 
spoonfuls  of  this  product  are  used  in  the  preparation  of 
sour  milk  by  adding  to  half  a  liter  of  a  fresh  quantity  of 
milk  which  has  been  boiled  and  allowed  to  cool.  Gartner's 
fat-milk,  obtained  by  the  mechanical  removal  of  part  of 
the  casein,  is  easil}'  digested  by  the  majority  of  gastric 
patients. 

Whey,  the  fluid  remaining  after  the  precipitation  of  casein, 
contains  protein,  milk  sugar,   poptono,   and   common   salt; 


MILK  03 

its  nutritive  value  is  small,  and  it  is  used  to  a  very  limited 
extent. 

Koumiss  and  Kefir. — Koumiss  and  kefir,  on  the  other  hand, 
are  most  excellent  milk  preparations.  Koumiss  is  prepared 
from  the  milk  of  either  mares  or  cows  by  lactic  acid  and 
alcoholic  fermentation.  It  contains  lactic  acid,  carbon 
dioxide,  and  alcohol,  and  has  an  agreeable,  slightly  acid  taste. 
Kefir  has  been  used  much  more  extensively  than  koumiss. 
It  is  prepared  by  means  of  kefir  tablets  or  pastilles,  which 
acting  upon  milk  produce  lactic  and  alcoholic  fermentation, 
the  result  of  which  is  a  thick,  cream-like,  acidulous  beverage. 
Boiled  milk,  cooled,  is  poured  over  the  kefir  ferment  and  left 
to  stand  for  twelve  hours  at  ordinary  room  temperature. 
It  is  then  stirred,  filtered,  and  placed  in  bottles,  which  are 
to  be  thoroughly  shaken  three  times  a  day  and  kept  in  a 
cool  place.  After  two  or  three  days  the  kefir  will  be  ready 
for  consumption.  The  advantage  of  kefir  is  that  it  contains 
small  quantities  of  carbon  dioxide  together  with  a  very  small 
percentage  (2  per  cent.)  of  alcohol.  When  ingested,  it 
hastens  the  secretion  of  hydrochloric  acid  and,  on  account 
of  the  action  of  the  carbon  dioxide,  increases  its  power. 

Yoghurt  Milk. — This  is  a  Bulgarian  sour  milk,  of  recent 
introduction  in  America,  but  long  used  in  the  East.  It  has 
a  high  nutritive  value,  employed  in  the  same  way  as  kefir. 

The  value  of  Yoghurt  milk  (pronounced  yowrd)  for  gastric 
patients  was  first  appreciated  by  the  Bulgarian  physician 
Grigoroff,  and  later  by  the  French  school.  It  is  similar  in 
many  ways  to  kefir  and  koumiss.  The  acidulation  is  gener- 
ated by  a  ferment  containing  three  kinds  of  bacteria,  the 
most  important  of  which  is  the  Bacillus  bulgaricus,  a  long 
bacillus  which  appears  both  singly  and  in  chains,  and  which 
can  be  stained  by  Gram's  method.  This  bacillus  is  able 
to  induce  fermentation  of  dextrose,  sugar  of  milk,  and  sac- 
charose, and  causes  the  coagulation  of  sterile  milk  within 
twelve  hours  by  the  formation  of  lactic  acid.  A  tem- 
perature of  60°  to  70°  C.  destroys  the  vitality  of  the 
germ  in  thirty  minutes.  The  composition  of  Yoghurt  milk 
and  its  relation  to  ordinary  sour  milk  (which  becomes  acid 


94  DIET  IN  GASTRIC  DISEASES 

by  mere  exposure  to  air),  to  kefir,  and  to  koumiss  may  be 
seen  from  the  following  table: 

Common 
Kefir.  Koum.iss.     sour  milk.       Yoghurt. 

Lactocasein 2.98  0.80^  2.70 

Lacto-albumin 0.28  0.30  I  3.55  0.98 

Peptones  and  albumoses     ...  0 .  05  1 .  04  J  3 .  75 

Fat 3.10  1.12  3.7  7.20 

Milk  sugar 2.78  0.39  4.5  9.40 

Lactic  acid 0.81  0.96  0.6  0.80 

Alcohol 0.70  3.19  ...  0.20 

Mineral  constituents     ....  0.79  0.33  0.71  1.38 

The  advantage  of  Yoghurt  milk  consists  in  the  fact  that 
its  casein  and  albumin  are  rendered  soluble  in  the  shape  of 
peptones  and  albumoses,  and  that  the  Hme  phosphates  have 
gone  into  solution  up  to  68  per  cent.  These  facts  serve  to 
explain  the  ready  digestibility  of  the  milk. 

Metchnikoff  ascribes  a  direct  life-prolonging  effect  to 
Yoghurt  milk,  and  he  bases  this  opinion  upon  the  fact  that 
in  Bulgaria,  where  Yoghurt  is  a  regular  article  of  diet, 
there  are  in  four  milUon  inhabitants  three  thousand  six 
hundred  consumers  of  Yoghurt  who  are  said  to  be  above 
one  hundred  years  of  age,  while  in  Germany,  with  a 
population  of  sixty-one  million,  there  are  only  about 
seventy  centenarians.  Granted  that  the  conclusions  of 
Metchnikoff  may  be  somewhat  erroneous,  it  must  still  be 
admitted  that  the  decomposition  processes  in  the  intes- 
tine and  the  whole  tissue  metamorphosis  are  favorably 
affected  by  the  use  of  Yoghurt.  Preparations  analogous  to 
Yoghurt  are  put  out  by  the  various  pharmaceutical  houses 
in  America.  Fairchild's  lactic  bacillary  tablets  are  said 
to  be  prepared  from  the  Bulgarian  bacillus.  Parke,  Davis 
&  Co.,  of  Detroit,  manufacture  a  Bacillus  bulgaricus  tablet 
(from  a  pure  culture  of  Bulgarian  lactic  acid  bacilli) 
which  when  added  to  sweet  milk  produces  a  beverage  that 
is  essentially  the  same  as  Yoghurt.  Preparations  of  a  similar 
nature  and  of  equal  merit  are  produced  by  Hynson,  ^^'estcott 
&  Co.,  of  Baltimore,  and  by  other  pharmaceutical  houses. 

Cheese. — Cheese  is  made  by  treating  raw  milk  with  rennet. 
The  resulting  coagulum  is  thoroughly  beaten  up,  and  then 


BREAD  95 

left  standing  to  mature.  The  casein  is  thereby  spHt  up  into 
various  decomposition  products  which  give  the  cheese  its 
characteristic  odor  and  taste.  Decomposed  cheese,  which 
is  looked  upon  as  a  delicacy  by  some  people,  should  not  be 
prescribed  for  patients  with  gastric  disease.  Almost  every 
normal  stomach  rebels  against  the  Roquefort  and  Limburger 
cheeses  with  their  characteristic  odor.  The  semi-putrid 
casein  cheese  should  never  be  eaten  even  by  healthy  people, 
not  to  mention  those  with  impaired  digestion. 

Bread. — Rye  bread  is  prepared  from  rye  flour  by  means 
of  yeasted  dough.  Brown  bread  and  ^^pumpernickle"  are 
made  from  rye  flour;  Graham  bread,  from  whole  wheat  meal. 
All  these  varieties  must  be  excluded  from  the  diet  of  gastric 
patients,  inasmuch  as  they  prove  a  source  of  irritation  to 
any  but  a  normal  stomach.  Yeast  dough  bread  in  the  intes- 
tinal tract  gives  rise  to  acid  fermentation,  producing  lactic, 
butyric,  and  acetic  acids,  carbon  dioxide,  and  hydrogen.  The 
finer  baked  foods,  especially  those  made  of  wheat,  as  white 
bread,  zwieback,  and  cookies  or  biscuits  prepared  by  the  addi- 
tion of  butter,  milk,  and  sugar,  are  especially  adapted  for 
gastric  treatment.  Ordinary  wheat  bread  should  be  given 
stale,  or  only  when  roasted — as  toast.  Fresh  and  very  soggy 
wheat  bread  retards  penetration  by  the  digestive  fluids  and 
is  difiicult  of  mechanical  subdivision.  Wheat  bread  toasted, 
zwieback,  and  biscuits,  like  the  crust  of  bread,  contain  their 
starch  in  the  form  of  dextrin,  which  is  easily  digested.  It  is, 
however,  necessary  that  patients  with  gastric  disease  should 
carefully  masticate  and  insalivate  these  baked  foods. 

There  is  a  mistaken  idea  among  the  laity  that  the  sick 
should  be  fed  pappy  liquid  substances  entirely  different  from 
the  food  taken  by  a  person  in  health.  If  we  except  foods 
that  contain  a  great  deal  of  irritating  waste,  there  is  no  rea- 
son why  the  diet  of  the  sick  should  differ  from  that  of  the  well. 
We  must,  however,  eliminate  fried  foods  and  fermentable 
vegetables.  Pure  white  bread  is  never  contraindicated,  and 
the  addition  of  butter  gives  it  a  high  calorific  value.  The 
bread  should  be  thoroughly  toasted  in  order  to  dextrinize  the 
carbohydrates  and  render  them  easily  digestible.    Crackers 


96  DIET  IX  GASTRIC  DISEASES 

can  frequently  be  substituted  for  bread.  Breads  made 
from  rye,  whole  wheat,  barley,  and  peas,  all  have  their 
advocates.  Too  great  efficacy  should  not  be  ascribed  to 
anj^  one  article  of  diet.  The  results  of  experiments  made  by 
Lauder  Brunton  show  that  the  '^deal"  bread  has  not  yet 
been  found.  Brunton  points  out  that  while  brown  bread 
contains  more  nitrogen  less  nitrogen  actually  gets  into  the 
blood  than  from  a  similar  weight  of  white  bread.  He  finds 
that  white  bread  is  not  only  more  digestible  and  less  likely 
to  cause  gastritis,  but  more  nutritious,  weight  for  weight, 
than  brown  bread. 

Grain  flours  are  used  not  only  in  the  baking  of  bread,  but 
in  the  preparation  of  soups.  The  gruel  soups  in  the  making 
of  which  the  grain  granules  are  first  boiled  and  then  pressed 
through  a  sieve  are  valuable  in  the  treatment  of  stomach 
diseases.  Oat  and  barley  gruel  are  prepared  after  this 
manner.  Their  mucoid  consistency  is  due  to  gluten  and 
broken-up  starch  granules.  Gruel  soups  protect  the  mucous 
membrane  of  the  stomach  from  the  irritating  effects  of 
other  foods  eaten  at  the  same  time.  Noodles,  macaroni, 
and  spaghetti  are  useful  farinaceous  dishes. 

Potatoes. — The  cheapness  of  and  the  large  percentage  of 
carbohydrates  in  potatoes  render  them  a  very  satisfactory 
food  for  all  classes  of  gastric  patients.  Potatoes  must  be 
given  properly  prepared — as  a  puree,  if  need  be,  with  the 
addition  of  milk  and  butter.  Other  tuberous  plants  used 
as  foods  are  much  poorer  in  carbohydrates  than  potatoes, 
and  should  be  eaten  only  when  they  can  be  prepared  in 
the  form  of  puree.  Hard  tubers,  such  as  radishes,  beetroots, 
and  onions,  are  contraindicated  in  cases  of  impaired  diges- 
tion. Sago  and  tapioca  as  porridge  or  soup  are  very  useful 
foods  for  gastric  patients. 

Rice. — Rice  has  usually  been  considered  an  inferior  food 
owing  to  the  excess  of  starch  (in  other  words,  deficiency  of 
protein)  in  its  composition;  and  this  is  undoubtedly  true  of 
rice  as  we  usually  get  it.  This  alleged  defect  in  the  grain  is 
due  to  the  removal  of  a  nutrient  substance  in  making  it 
presentable  for  the  market  by  what  is  known  as  the  polish- 


SUGAR  07 

ing  process.  Not  only  the  outer  husk,  but  what  is  known 
as  the  "rice  meal,"  which  envelops  the  inner  kernel,  is 
removed,  despite  the  fact  that  this  is  the  most  nutritious 
part  of  the  grain.  Analysis  of  "rice  meal"  made  at  the  in- 
stance of  Dr.  George  Reith,  in  1900,  showed  it  to  contain 
12.5  per  cent,  of  protein  and  4.5  per  cent,  of  phosphoric 
acid.  The  Japanese,  in  common  with  other  rice-eating  peo- 
ples, polish  only  the  grain  that  is  intended  for  export;  what 
is  kept  for  home  consumption,  being  unpolished,  possesses  a 
much  larger  proportion  of  nutriment  and  a  flavor  which  the 
polished  grain  lacks.  Rice  in  its  natural  condition  is,  there- 
fore, a  very  nutritious  article  of  food;  it  is  easily  digested, 
and  quite  suitable  for  patients  with  impaired  digestion. 

Green  Vegetables. — Green  vegetables  and  the  various  kinds 
of  cabbage  contain  very  little  protein  and  only  a  small  quan- 
tity of  carbohydrates.  Prepared  as  purees  they  are  permis- 
sible, however.  The  small  percentage  of  cellulose  in  green 
vegetables  is  no  contraindication  to  their  use.  A  patient 
with  gastric  disease  should  not,  however,  eat  vegetables 
which  cannot  be  finely  divided.  The  tops  only  of  asparagus 
are  permissible.     Mushrooms  are  contraindicated. 

Legumes. — Peas,  beans,  and  lentils  are  all  rich  in  protein, 
containing  about  20  to  25  per  cent.,  and  50  per  cent,  of 
carbohydrates.  They  are  consequently  very  nutritious 
substances,  and,  when  well  cooked  and  carefully  strained, 
suitable  for  gastric  patients. 

Fruit. — Fruit  contains  less  protein  than  do  vegetables,  but 
a  larger  quantity  of  carbohydrates  in  the  shape  of  dextrose 
and  levulose.  The  refreshing  taste  of  fruit  is  due  to  various 
fruit  acids,  such  as  malic  acid  in  apples,  tartaric  acid  in 
grapes,  and  citric  acid  in  lemons.  Patients  with  gastric 
disease  should  take  fruit  only  when  it  is  cooked  by  boiling. 

Sugar. — Cane  sugar,  grape  sugar,  milk  sugar,  or  fruit  sugar 
may  be  eaten  by  patients  with  gastric  disease,  within  certain 
limits.  Solutions  of  sugar  cause  n  the  stomach  a  decreased 
secretion  by  the  gastric  glands.  Since  they  inhibit  the 
secretion  of  hydrochloric  acid,  thej^  are  applicable  in  con- 
ditions of  hyperacidity.    Morgan  carefully  experimented  on 

7 


98  DIET  IN  GASTRIC  DISEASES 

several  persons  with  cane  sugar,  making  repeated  gastric 
analyses ;  he  concluded  that  sugar  in  considerable  amounts 
in  the  diet  of  either  the  healthy  or  the  sick  depresses  the 
secretory  functions  of  the  stomach.  In  hyperchlorhydria 
a  diet  containing  large  amounts  of  sugar  diminishes  the 
secretion  of  hydrochloric  acid  in  about  the  same  propor- 
tion as  it  does  in  a  healthy  stomach.  According  to  Abel/ 
three  or  four  ounces  of  sugar  can  be  digested  by  the  healthy 
adult  without  difficulty.  Saccharin  occasionally  gives  rise 
to  indigestion. 

Spices. — Small  quantities  of  common  salt  stimulate  the 
secretion  of  gastric  juice;  large  quantities  hinder  digestion. 
The  ingestion  of  salt  in  cases  of  gastric  disease  has  to  be 
regulated  according  to  the  findings  on  analysis  of  the 
stomach  contents.  In  addition .  to  sodium  chloride,  the 
alkahne  phosphates  and  earths  are  made  use  of  in  the 
human  economy.  They  are,  however,  present  in  ordinary 
food  in  sufficient  quantity  for  this  purpose.  Only  very  few 
spices  should  be  allowed  in  the  dietary  of  gastric  patients. 
Vanilla  and  cinnamon  are  harmless.  Practically  all  other 
spices  must  be  eliminated,  or  used  with  care  for  the  purpose 
of  stimulating  an  insufficient  secretion  of  gastric  juice. 

Water. — Water  stimulates  secretion  slightly;  it  remains  in 
the  stomach  for  a  comparatively  long  time,  and  acts  as  a 
diluent.  The  artificial  waters  charged  with  carbon  dioxide 
have  no  place  in  the  dietary  of  stomach  patients.  The 
natural  mineral  waters,  however,  excite  peristaltic  action 
and  have  a  slightly  anesthetic  effect  upon  the  mucous  mem- 
brane of  the  stomach.  Strong  natural  waters,  like  the 
artificial  substitutes,  contain  too  much  carbon  dioxide,  and 
consequently  have  a  harmful  effect  upon  t^e  stomach.  Not 
more  than  eight  ounces  of  water  should  be  taken  at  one 
time.  Water  is  not  absorbed  by  the  stomach.  The  di'inking 
of  ice  water  is  harmful,  inasmuch  as  it  temporarily  paralyzes 
the  pyloric  closure,  so  that  the  stomach  contents  are  in  dan- 
ger of  being  emptied  at  once  into  the  duodenum.     Accord- 

'  Unitt'd  Stiitcs  Dcparlinent  of  Agriculture,  IJulIotiu  1)3. 


ALCOHOL  99 

ing  to  Bettmann,  large  draughts  of  hot  water  benefit  those 
who  are  well  nourished  and  whose  digestive  tract  is  well 
supplied  with  muscular  tissue.  Large  draughts  of  hot  water, 
taken  on  retiring,  are  beneficial  to  corpulent  people  who  are 
subject  to  ''bilious  attacks"  so  called,  or  who  are  affected 
with  gastric  catarrh.  An  aperient  pill  swallowed  at  bedtime 
with  a  large  tumblerful  of  hot  water  is  usually  all  the  medi- 
cine that  is  necessary  to  keep  such  patients  comfortable. 
Hot  water  taken  before  meals,  either  with  or  without  phos- 
phate or  sulphate  of  soda,  is  also  beneficial.  It  acts  by 
dissolving  and  washing  out  of  the  stomach  the  accumulated 
mucus.  Such  treatment,  however,  instituted  in  cases  of 
motor  insufficiency,  almost  invariably  does  harm.  At  first 
the  patients  experience  some  relief,  but  after  one  or  several 
weeks  all  their  symptoms  return  in  an  aggravated  form. 
This  is  explained  by  the  fact  that  when  the  digestive  tract 
is  relaxed  and  muscularly  weak  the  stomach  is  unable  to 
propel  large  quantities  of  fluid  into  the  intestine.  In  such 
cases  it  is  always  difficult  to  get  sufficient  water  into  the 
system.  The  stomach  should  not  be  overloaded  with  water 
at  any  one  time,  but  water  should  be  taken  in  small  quanti- 
ties and  frequently. 

Alcohol. — The  combustion  of  protein  and  fat  is  diminished 
after  small  quantities  of  alcohol  are  taken.  In  acting  as  a 
fat-sparer,  alcohol  itself  is  consumed  and  yields  heat  and 
energy  to  the  body;  it  is,  therefore,  to  a  certain  degree 
a  food.  Alcohol  is  usually  consumed  in  the  shape  of 
champagne,  beer,  wine,  whisky,  brandy,  or  other  concen- 
trated spirituous  liquor.  The  general  effect  of  alcohol  in 
small  quantities  and  in  not  too  concentrated  form  on  gastric 
digestion  is  to  stimulate  secretion;  but  large  quantities  and 
the  concentrated  drinks  (liquors)  retard  digestion. 

According  to  Chittenden,  Mendel,  and  Jackson, ^  alcohol 
and  alcoholic  fluids  have  a  marked  effect  on  gastric  secre- 
tion, increasing  very  greatly  the  flow  of  gastric  juice  and 
also  its  content  of  acid  and  total  solids.    Furthermore,  this 

1  American  .Journal  of  Physiology 


100  liJET  IN  GASTRIC  DISEASES 

action  is  exerted  not  only  by  the  alcoholic  fluids  in  the 
stomach,  but  also  reflexly  through  the  influence  of  alcohol 
absorbed  from  the  intestine.  Ordinary  ethyl  alcohol  intro- 
duced into  the  empty  stomach  of  dogs,  with  the  duodenum 
ligated,  exhibits  a  markedly  stimulating  action  upon  gastric 
secretion  as  compared  with  the  action  of  water  under  like 
conditions.  Not  only  does  it  increase  the  volume  of  gastric 
juice  very  greatly,  but  it  increases  its  acidity  as  well  as 
the  content  of  solid  matter.  Moreover,  alcohol  absorbed 
from  the  intestine,  the  latter  being  entirely  shut  off  from 
the  stomach,  may  likewise  cause  stimulation  of  the  gastric 
glands,  with  a  marked  increase  in  the  rate  of  secretion. 
Whisky,  brandy,  sherry,  claret,  beer,  and  porter  all  have 
the  same  effect  in  stimulating  gastric  secretion.  The 
gastric  juice  under  alcoholic  stimulation  is  strongly  pro- 
teolytic. 

If  these  results  are  considered  in  connection  with  our 
previous  observations  upon  the  influence  of  alcohol  and 
alcoholic  drinks  upon  the  purely  chemical  processes  of 
gastric  digestion  it  is  seen  that,  side  by  side  with  more  or 
less  retardation  of  digestive  proteolysis  caused  by  alcoholic 
beverages,  there  occurs  an  increased  flow  of  gastric  juice, 
rich  in  acid  and  of  unquestionable  digestive  power.  The 
two  effects  may  thus  normally  counterbalance  each  other, 
though  it  is  evident  that  modifying  conditions  may  readily 
retard  or  stimulate  the  processes  in  the  stomach  accord- 
ing to  circumstances.  Foremost  among  these  is  the  rapid 
disappearance  of  alcohol  from  the  alimentary  canal.  The 
administration  of  alcohol  must  be  guided  accordingly  when 
considering  its  employment  in  gastric  disease.  Boas  abso- 
lutely forbids  alcohol  in  cases  of  gastric  neurasthenia.  Beer 
should  be  avoided  in  the  great  majority  of  stomach  ]ia- 
tients,  inasmuch  as  it  dilutes  the  gastric  juice  and  induces 
fermentative  processes,  due  to  the  yeast  contained  in  the 
beverage.  With  respect  to  wine,  in  light  cases  ])ossi])ly  a 
very  mild,  good  quality  claret,  diluted  if  need  be,  should  l)c 
considered.     In  acute  cases  champagne  is  a  fairly  practical 


TEA  AND  COFFEE  101 

analeptic.    Cognac  and  other  concentrated  liquors  are  quite 
inadmissible  in  cases  of  stomach  disease. 

Tea  and  Coffee. — Coffee  stimulates  the  secretion  of  the  gas- 
tric glands  and  increases  the  peristaltic  movements  of  the 
intestine.  Tea  has  a  constipating  effect  on  account  of 
the  large  amount  of  tannic  acid  it  contains,  and  in  animal 
experiments  it  retards  the  secretion  of  acid  and  delays  the 
peptonization  of  protein  substances.  Coffee  should  be  for- 
bidden in  most  cases  of  gastric  disease.  Very  weak  tea, 
on  the  contrary,  may  be  taken  with  advantage,  especially 
if  used  as  a  vehicle  for  milk  or  other  nutritive  materials. 
In  health,  however,  there  is  no  reason  for  apprehending 
danger  to  the  race  at  large  from  coffee-drinking.  Coffee- 
drinking  has  not  affected  Americans  to  any  appreciable 
degree,  though  coffee  has  been  the  almost  universal  bever- 
age for  many  decades.  The  life  insurance  companies,  con- 
stantly warring  against  everything  that  tends  to  shorten 
life,  are  silent  in  regard  to  coffee  as  a  beverage.  The  experi- 
ments of  Chase  on  three  normal  individuals  who  were  not 
addicted  to  tea  or  coffee  show  that  when  taken  wdth  meals, 
in  the  amounts  ordinarily  used,  these  beverages  do  not  retard 
either  salivary  or  peptic  digestion.  It  has  been  found  that 
salivary  digestion  is  aided  slightly  by  tea.  Both  tea  and 
coffee  may  act  as  mild  stimulants  to  gastric  secretion;  the 
digestive  power  of  the  secretions,  however,  is  not  augmented, 
but,  on  the  other  hand,  neither  is  it  impaired,  as  in  the  use 
of  whisky.  Therefore,  as  a  stimulant  to  gastric  secretion, 
tea  or  coffee  would  seem  preferable  to  whisky.  In  the 
tests  wdth  these  beverages,  strong  black  tea  and  a  10-per- 
cent, strength  of  coffee  (coffee  10  Gm.,  water  100  Cc.)  were 
used.  Both  the  strengths  and  amounts  used  were  sufficient 
to  show  any  harmful  effects  which  might  be  produced  by 
these  fluids  as  ordinarily  taken.  Admitting  the  generally 
harmful  effects  of  large  quantities  of  tea  and  coffee,  there 
seems  to  be  an  undue  prejudice  against  the  use  of  these 
beverages,  judging  from  laboratory  experiments.  A  great 
deal  has  been  said  about  the  deleterious  effects  of  tea  and 


102  DIET  IX  GASTRIC  DISEASES 

coffee  on  the  stomach.  Apart  from  their  stimulatmg  effect 
on  the  central  nervous  system,  if  properlj^  made  and  not 
too  strong,  their  effect  on  digestion  is  almost  neutral. 

Cocoa.  —  Cocoa  possesses  much  higher  nutritive  value 
than  tea  or  coffee.  It  does  not  stimulate  gastric  diges- 
tion, and  prepared  with  either  water  or  milk  it  is  a  proper 
beverage  for  patients  with  stomach  disease.  Prepara- 
tions of  cocoa  from  which  the  oil  has  been  expressed,  and 
which  have  not  been  treated  with  alkalies,  are  to  be  recom- 
mended. Chocolate  prepared  by  admixture  of  sugar  and 
spices  is  not  so  easily  digested.  It  contains  a  larger  pro- 
portion of  fat  and  carbohydrates,  and  may,  therefore,  give 
rise  to  fermentation  and  the  formation  of  acid. 

Tobacco. — The  use  of  tobacco  in  am^  form  is  to  be  inter- 
dicted in  all  cases  of  stomach  disease,  because  clinically 
tobacco  has  often  proved  to  be  the  cause  of  chronic  gastritis 
and  its  sequelsB.  Nicotine  may  reduce  the  peristaltic  motions 
of  the  stomach  in  consequence  of  its  paralyzing  effect  on 
the  vagus  nerA^e.  Tobacco  may  cause  hyperacidity  in  the 
empty  stomach.  Smoking  after  meals  induces  sahvation, 
and  when  the  saliva  is  swallowed  the  acid  secretion  of  the 
stomach  becomes  neutralized. 

The  patient  must  be  definitely  instructed  in  regard  to  what 
articles  of  diet  are  permissible  and  what  are  not.  Printed 
schedules  are  frequently  provided  for  this  purpose.  The 
permissible  and  the  forbidden  foods  are  all  enumerated  on 
these,  and  those  unsuitable  for  the  patient  are  crossed  off. 
The  following  dietary  sheet  of  Cramer  is  given  as  an 
example : 

GENERAL  INSTRUCTIONS 

Preparation  and  Selection  of  Food. — Eat  slowly  of  food  wluch  is  not  too 
hot;  chew  well.  Do  not  drink  during  a  meal.  Keep  fixed  meal  hours.  Do 
not  eat  too  late  at  night,  i.  e.,  no  later  than  two  hours  before  retiring.  In 
the  preparation  of  food  use  no  lard,  but  butter  only,  anil  only  the  quantity 
absolutely  necessary.  Avoid  all  sharp  spices  (salt  must  be  the  chief  condi- 
ment).    The  meat  must  not  be  too  fresh.     Game  must  not  be  jiickled 


DIET  LIST 


103 


Prohibited: 


DIET  LIST 


Fatty   and  acid   foods,  Coarse  vegetables,  such     Vegetable  soups. 

fried  foods,  lard,  ham,  as    cabbage,    cucum-     Chocolate,   beer,   wine, 

and    smoked     meats,  bers,  horseradish;  sal-         champagne,    liquors, 

strongly  spiced  foods.  ads  of  all  kinds.  Fresh 

Sauces    (flour  gravies),  fruit,     jam,      cheese, 

fried     potatoes,    leg-  black    bread,    sweets 

umes,     peas,    lentils,  of  every  description, 
white    beans,    chest- 
nuts. 

II.     Permissible: 

First  breakfast:  Milk;  coffee,  tea,  or  cocoa,  with  milk;  white  bread  (zwie- 
back), butter,  one  soft-boiled  egg,  fried  veal  sausage,  cold  roast 
beef,  buttermilk,  kefir,  oatmeal. 

Dinner:  Oysters  on  half-shell. 

Soups:  Gruel,  rice,  milk,  sago,  macaroni,  egg,  bouillon. 

Meat:  Moderate  quantities — Roast  beef,  veal,  lamb,  chicken, 
squab,  game  (except  boar  and  wild  duck);  boiled  beef,  breast  of 
veal,  brain  of  veal,  calf's  feet,  chicken,  and  squab. 

Fresh  fish:  Pike,  white  fish,  trout,  codfish — boiled  in  salt  water  or 
baked,  not  fried. 

Vegetables  and  side  dishes:  Potato  puree  (without  onions),  baked 
potatoes  mashed,  steamed  rice,  water  noodles,  macaroni  spa- 
ghetti, spinach,  green  lettuce,  cauliflower,  green  peas  (puree), 
asparagus  tips,  yellow  carrots  (puree). 

Farinaceous  foods:  Light  puddings. 

Supper:  Cold  or  warm  meat  in  moderate  quantities.  Side  dishes  same 
as  dinner^,    A  cup  of  milk,  coffee  or  tea  with  milk,  and  zwieback. 


Lists  of  this  nature  may  be  dispensed  with,  for  it  is  pref- 
erable for  the  physician  to  write  a  hst  of  foods  to  suit  the 
individual  case.  Boas  advises  that  only  the  foods  permis- 
sible be  marked  on  the  diet  list.  It  is  evident  that  the  lines 
should  not  be  drawn  too  exactly  with  respect  to  the  per- 
missible foods.  The  prescription  must  be  adapted  to  each 
case. 

The  physician  should  aim  at  avoiding  unnecessary  mo- 
notony in  food  arrangements.  If  possible,  food  luxuries 
and  spices  should  be  permitted  to  such  an  extent  as  to- 
render  the  prescribed  diet  relishable. 


104  DIET  IX  GASTRIC  DISEASES 

It  is  quite  proper,  indeed  necessary,  to  give  exact  counsel 
regarding  the  quantities  of  food  to  be  taken :  and  the  physi- 
cian should  not  confine  himself  to  such  general  measure- 
ments as  spoonfuls,  cups,  and  glasses,  the  standards  of 
which  vary  so  widely.  The  quantity  is  more  accurately 
specified  in  grammes,  as:  Of  fruit  preserves,  the  portion 
for  a  patient  with  gastric  disease  should  not  exceed  150 
grammes  (five  ounces).  Hints  regarding  the  mode  of  prep- 
aration of  food  must  Ukewise  be  carefully  given:  e.  g., 
whether  meat  should  be  eaten  raw  boiled,  or  roasted:  in 
what  form  and  state  of  subdivision  the  various  foods  are 
to  be  taken  (puree,  mashed  etc.);  to  what  extent  fats  and 
spices  may  be  employed  in  the  preparation  of  the  dishes ;  and 
how  strong  tea  or  coffee  may  be  made. 

It  is  quite  essential,  too,  to  impress  upon  the  patient  the 
number  of  meals  to  be  taken,  and  at  what  hours.  The 
rule  is,  light  meals  at  frequent  intervals.  This  holds  good 
particularly  in  cases  of  atony,  dilatation,  and  pyloric  stenosis, 
because  in  such  conditions  large  quantities  are  verj^  difficult 
to  manage.  In  some  cases  where  hypersecretion  is  a  feat- 
ure, the  intervals  between  meals  should  be  extended  in 
order  to  provide,  if  possible,  adequate  periods  of  rest  for 
the  irritated  gastric  mucous  membrane.  Deviations  from 
the  usual  dining  schedule  should  be  as  infrequent  as  pos- 
sible. Irregularity  in  eating  is  apt  to  prolong  the  stay  of 
the  food  in  the  stomach.  The  patients  should  not  retire 
earher  than  two  hours  after  partaking  of  the  evening  meal. 
Mastication  and  oral  digestion  are  of  the  utmost  impor- 
tance. Only  when  these  are  accomplished  in  a  correct 
manner  is  it  possible  for  the  food  to  reach  the  stomach 
in  such  a  condition  as  to  facilitate  its  penetration  and 
solution  by  the  digestive  juices. 

Patients  should  eat  slowly.  Prolonged  mastication  not 
only  thoroughly  insalivates  the  food,  but  it  has  a  favorable 
and  stimulating  effect  on  the  secretion  of  the  gastric  juices. 
During  the  meal  no  strain  should  be  put  upon  the  mind, 
consecjuently  reading  while  eating  is  to  be  forbidden.  Anger, 
excitement,  and  irritating  discussions  must  be  avoided  at  the 


DIET  LIST  105 

table.     When  the  patient  has  no  appetite  he  is  not  to  be 
coaxed  or  harassed  into  taking  food. 

The  temperature  of  both  food  and  drink  is  of  importance. 
The  harmfuhiess  of  overcold  or  superheated  beverages  is 
well  known  and  has  already  been  discussed.  Boas  gives  a 
list  of  foods  and  beverages,  with  the  temperatures  at  which 
they  may  be  consumed  with  most  benefit: 

Appropriate 
temperature 
(Centigrade). 

Water 12°  to  13° 

Seltzer  and  aerated  water      .      .      . 10°  to  12° 

Hock  or  white  wine 10° 

Claret 16°  to  18° 

Beer 12°  to  15° 

Coffee  or  tea not  above  40°  to  43° 

Beef  broth  (milk  and  flour  soups)     .      .      .       not  above  37°  to  45° 

Mashed  (pudding)  foods 37°  to  42° 

Milk      ....       not  below  16°  to  18°  C,  nor  above  33°  to  40° 

Roast  meats 40° 

Bread not  above  30° 

Beverages  in  moderate  quantities  are,  as  a  rule,  without 
evil  influence  in  health.  In  gastric  diseases,  however,  drink- 
ing during  the  meals  is  probably  better  omitted. 

Immediately  after  eating,  fatiguing  bodily  or  mental 
exercise  should  not  be  taken.  Vigorous  bodily  exertions 
at  such  a  time  produce,  even  in  health,  sensations  of  dis- 
comfort; in  disease  they  are  positively  harmful,  as  they  are 
liable  to  diminish  the  secretion  of  hydrochloric  acid  in  the 
stomach.  A  patient  with  gastric  disease  should  lie  down 
after  eating,  and  on  his  right  side,  since  in  that  position  the 
stomach  is  emptied  more  rapidly.  The  clothing  should  not 
bind  the  stomach. 

It  is  an  open  question  whether  patients  should  sleep  after 
dinner;  in  the  majority  of  cases  this  may  be  left  to  the 
patient  himself.  The  percentage  of  acid  in  the  stomach, 
and  the  motility  of  that  organ,  are  said  to  be  diminished 
during  sleep.  These  facts  must  be  borne  in  mind  when  con- 
sidering the  advisability  of  either  forbidding  or  permitting 
the  after-dinner  nap. 


CHAPTER    IV 

ARTIFICIAL   FOOD   PREPARATIONS 

In  cases  where  the  general  nutrition  is  low  and  onlj^  small 
quantities  of  food  can  be  ingested,  it  has  been  found  neces- 
sary to  supplement  the  "natural"  diet  by  the  use  of  specially 
prepared  nourishing  agents.  We  have  a  large  number  of 
such  preparations  at  our  disposal. 

To  take  the  place  of  proteolysis  in  the  stomach,  which  is 
so  frequently  deficient  in  chronic  gastric  diseases,  a  number 
of  nutritious  preparations  are  manufactured  in  which  the 
protein  is  predigested  into  peptones  and  albumoses.  Prep- 
arations of  this  class  are  not  necessary  when  the  patient  is 
able  to  digest  sufficient  food  for  his  requirements;  but  they 
are  indicated  in  cases  where  the  general  nutrition  is  low. 
Many  of  them  are,  however,  impracticable,  owing  to  their 
disagreeable  taste;  and  the  cost  of  those  that  can  be  used 
is  generally  so  high  as  to  curtail  their  usefulness  among 
patients  in  moderate  circumstances. 

The  protein  preparations  are  made  by  artificial  digestion 
of  protein  by  means  of  animal  and  vegetable  ferments  with 
the  aid  of  organic  and  inorganic  acids,  salts,  bases,  vapors, 
and  gases,  in  a  vacuum  or  under  high  pressure.  The  prin- 
cipal preparations  of  this  class  include  the  following: 

Preparations  of  Animal  Protein.  —  Somatose  is  a  3'ellowish 
powder,  nearly  tasteless  and  odorless,  and  readily  soluble 
in  water.  It  contains  over  90  per  cent,  of  albumoses,  is 
easily  assimilated,  and  stimulates  appetite  and  gastric 
secretion.  It  has  been  employed  with  benefit  in  chronic 
gastritis,  in  gastric  crises,  after  surgical  operations  on 
the  stomach,  in  the  cachexia  of  carcinoma,  in  nervous 
dyspepsia  and  anorexia,  and  in  acute  gastroenteritis. 
Somatose  is,  however,  not  well  borne  in  hyperacidit3^ 
The  dose  is  three  to  four  dessertspoonfuls  a  day.  Its 
proper  use  is  as  an  adjuvant  in  connection  with  the  pre- 
scribed diet,  to  increase  the  nutritive  value  of  the  latter. 


PEPTONES  107 

Somatose  has  the  action  of  a  tonic  rather  than  that  of  a 
food.  Liquid  somatose  has  been  furnished  by  pharmaceutical 
houses.  In  iron  somatose  the  iron  is  organically  combined; 
this  preparation  is  indicated  in  cases  of  chlorosis  compli- 
cated with  gastric  disturbance;  the  adult  dose  is  three  to 
four  dessertspoonfuls  daily. 

Caringen,  or  Sotnatine,  occupies  a  place  between  somatose 
and  meat  extract  as  regards  composition;  its  effect  is  stimu- 
lating.   Its  cost  renders  it  impracticable  as  a  food. 

Tropon  is  prepared  from  animal  and  vegetable  protein, 
and  is  useful  as  a  cheap  meat  powder.  It  contains  90 
to  99  per  cent,  of  protein,  and  is  insoluble  in  water. 
It  is  administered  in  bouillon,  milk,  cocoa,  and  soup.  The 
quantity  to  be  given  should  be  boiled  with  a  small  portion 
of  the  nutrient  vehicle  in  which  it  is  to  be  taken  and  then 
mixed  with  the  entire  amount. 

Salvatose,  a  French  preparation,  is  a  pure  protein  product. 
It  is  seldom  used. 

Fersan  contains  80  to  90  per  cent,  of  organically  com- 
bined soluble  protein.  It  is  fresh  ox-blood  mixed  with 
twice  its  volume  of  a  1-per-cent.  solution  of  sodium 
chloride  and  then  centrifugalized,  completely  separating  the 
blood  corpuscles  from  the  serum  containing  the  metabolic 
products.  The  corpuscular  mass  is  shaken  with  ether  and 
the  ethereal  solution  treated  with  concentrated  hydrochloric 
acid  under  certain  conditions.  The  acid  albuminous  sub- 
stance thus  precipitated  is  washed  with  absolute  alcohol, 
dried  in  vacuo,  and  powdered.  Fersan  is  a  dark  brown, 
odorless  powder  with  a  slightly  acid  taste,  soluble  in  water, 
and  containing  a  large  percentage  of  iron  and  phosphorus. 
The  phosphorus  is  present  in  complete  organic  combination, 
and  the  iron  almost  entirely  so.  The  preparation  is  an  iron 
albuminate  that  calls  for  no  digestive  activity  on  the  part  of 
the  stomach.  It  is  not  coagulated  in  the  stomach,  and  is 
completely  absorbed  by  the  intestine.  The  dose  is  three  to 
six  teaspoonfuls  a  day,  in  milk. 

Peptones. — Peptone  preparations  are  now  but  seldom  em- 
ployed.   Their  nutritive  value  is  due  chiefly  to  the  albumoses 


108  ARTIFICIAL  FOOD  PREPARATIONS 

they  contain.  Laboratory  experimentation  and  clinical  ex- 
perience have  shown  that,  in  order  to  obtain  sufficient 
nourishment  from  the  peptone  preparations,  unduly  large 
quantities  must  be  ingested.  Peptones  have,  as  a  rule,  a 
disagreeable  taste.  In  large  doses  they  tend  to  produce 
diarrhea.  Among  the  most  satisfactory  preparations  of  this 
class  the  following  ma}'  be  briefly  mentioned :  Pepton-Liebig 
(Kemmerich)  stimulates  the  appetite.  The  meat  solution 
of  Leube-Rosenthal  contains  9  to  12  per  cent,  of  soluble 
protein  and  1.8  to  6.6  per  cent,  of  peptone.  Peptone 
chocolate  contains  only  6  per  cent,  more  protein  than  the 
ordinary  cocoa.  Denayer's  fluid  meat  peptone  is  merely  a 
strong  beef  tea,  pleasant  to  the  taste,  used  principally  as 
a  stimulant,  containing  1.5  per  cent,  peptone  and  10.5  per 
cent,  a  bumoses.  Koch's  peptone  contains  18.8  per  cent, 
peptone,  16  per  cent,  propeptone,  and  1.4  per  cent,  insolub'e 
protein.  Cibil's  peptone  contains  28.1  per  cent,  peptone 
and  5.8  per  cent,  albumoses. 

Among  the  artificial  food  preparations  made  in  the  United 
States  we  have  the  following,  with  their  nutritive  value  as 
determined  by  the  Council  of  Pharmacy  and  Chemistry  of 
the  American  Aledical  Association: 


( 

[Carbohy- 

Name of  substance. 

Name  of  manufacturer. 

drates. 

Protein 

1. 

Carpanutrine 

John  Wyeth  &  Bro. 

5.34 

4.28 

2. 

Carpanutrine 

John  Wyeth  &  Bro. 

5.78 

6.24 

3. 

Liquidpeptones 

Eli  Lilly  &  Co. 

6.05 

4. .50 

4. 

Liquidpeptones  with  Creo.sote 

Eli  Lilly  &  Co. 

13.47 

3.84 

5. 

Liquidpeptonoid.s 

Arlington  Chemical  Co. 

10.57 

4.93 

6. 

Liquidpeptonoid.s 

Arlington  Chemical  Co. 

11.53 

4..53 

7. 

Predigested  Beef 

H.  K.  Mulford  Co. 

4.37 

2.38 

8. 

Predigested  Beef 

H.  K.  Mulford  Co. 

4.55 

2.59 

9. 

Nutrient  Wine  of  Beef  Peptone 

'  Armour  &  Co. 

15.43 

0.64 

10. 

Nutrient  Wine  of  Beef  Peptone 

Armour  &  Co. 

15.57 

0.43 

11. 

Nutritive  Liquid  Peptone 

Parke,  Davis  &  Co. 

12.89 

1.86 

12. 

Nutritive  Liquid  Peptone 

Parke.  Davis  &  Co. 

13.19 

1.16 

13. 

Panopeptone 

Fairrhild  Bros.  &  Foster  11.92 

6.38 

14. 

Panopeptone 

Fairchild  Bros.  &  Foster  10.0.5 

6  33 

15. 

Peptonic  Elixir 

Wm.  Mcrrell  Chem.  Co, 

,  11.46 

2. .54 

16. 

Tonic  Beef  S.  &  D. 

Sharp  &  Dohme 

2.36 

3.40 

17. 

Tonic  Beef  S.  &  D. 

Sharp  &  Dohme 

2.22 

3.28 

18. 
19. 

Liquid  Peptone 

Cow's  Milk  (3w.  oer  cent,  fat) 

Stevenson  &  Jester  Co. 

0.55 
4.80 

1.81 
3.50 

PEPTONES  109 

There  are  no  fatty  substances  in  these  products;  their 
food  vakie  from  this  point  of  view  is,  therefore,  a  negative 
quantity.  They  all  contain  alcohol;  the  proportion  ranges 
from  14  to  23  per  cent.  The  printed  matter  distributed 
by  some  manufacturers  leads  the  physician  to  believe  that 
these  preparations  contain  sufficient  nutritive  material  to 
maintain  the  normal  nutrition  of  the  body.  The  average 
quantity  that  can  be  taken  daily  ranges  from  50  to  150  Cc, 
the  total  available  calories  of  which,  based  on  the  protein 
and  carbohydrate  bodies,  varies  from  9.8  to  110.5.  Adding 
to  these  figures  the  amount  of  energy  represented  by  the 
alcohol,  in  each  case,  the  total  available  calories  will  vary 
from  55  to  229.5.  The  number  of  calories  required  per 
diem  by  a  man  doing  very  moderate  work  approximates 
3000.  In  sickness  the  amount  required  is  not  so  great,  but 
on  the  average ,  should  not  fall  much  below  1500  calories  for 
the  twenty-four  hours.  This  consideration  alone  shows  the 
fallacy  of  the  representation  that  any  of  the  artificially 
prepared  foods  above  mentioned  will  enable  the  patient  to 
dispense  with  other  nourishment. 

The  report  of  the  Council  of  Pharmacy  and  Chemistry 
goes  on  to  say: 

''In  order  to  get  a  fair  conception  of  the  actual  food 
value  of  these  various  preparations,  it  is  desirable  to  make 
some  comparison  which  can  be  readily  comprehended  by 
every  physician.  The  amount  of  good  milk  necessary  each 
twenty-four  hours  to  sustain  the  vitality  of  a  patient  during 
a  serious  illness  is  not  less  than  64  ounces,  or  approximately 
2000  Cc.  The  food  value  in  calories  represented  by  this 
amount  of  good  milk  may  be  placed  at  1430.  This  includes 
not  only  the  protein  and  carbohydrate  matter,  but  the 
fat  as  well.  By  comparing  this  available  potential  energy 
with  the  total  energy  available  in  the  predigested  foods 
under  consideration,  it  can  be  readily  seen  that  if  a  physician 
depends  on  the  representations  made  by  some  of  the  manu- 
facturers, and  feeds  his  patient  accordingly,  he  is  resorting 
to  a  starvation  diet.  The  largest  number  of  available 
calories,  including  alcohol,  present  in  any  of   the   recom- 


no  ARTIFICIAL  FOOD  PREPARATIONS 

mended  daily  doses  is  less  than  one-fifth  of  the  number 
of  calories  represented  by  2000  Cc.  of  milk;  and  the  calories 
represented  by  the  daily  dose  of  the  preparation  poorest 
in  food  products  is  only  one-twenty-fifth  of  the  amount 
present  in  2000  Cc.  of  milk.  These  figures  tell  their  own 
story. 

''Making  2000  Cc.  of  milk  the  basis  of  calculation,  and 
estimating  the  amount  of  the  various  preparations  required 
to  yield  this  number  of  calories,  it  is  found  that  the  quantity 
to  be  administered  daily  to  supply  1430  calories,  including 
alcohol,  varies  from  716.2  to  1506.2  cubic  centimeters  (or 
approximately  one  to  three  pints).  In  many  cases  the 
amount  of  alcohol  exhibited  by  these  quantities  would  keep 
the  patient  in  an  alcoholic  stupor  continually.  The  cost 
necessary  to  supply  this  energy  varies  from  $1.48  to  $3.39. 
Compare  these  prices  with  the  cost  of  two  quarts  of  milk. 
Is  further  comment  necessary? 

''The  average  number  of  calories  represented  by  500 
grammes  of  these  products  as  proteins  and  carbohydrates  is 
260.6.  The  total  average  calorific  value  of  the  same  amount 
of  these  foods  is  802.4. 

"The  number  of  calories  represented  by  good  brandies 
or  whiskies,  containing  45  per  cent,  of  alcohol,  is  1575. 
In  other  words  the  average  calorific  value  of  these  prepa- 
rations is  approximately  one-half  that  contained  in  either 
good  brandy  or  whisky.  From  this  it  must  not  be  con- 
cluded, however,  that  equal  quantities  of  brandy  or  whisky 
are  twice  as  valuable  as  the  medicinal  foods,  because  the 
medicinal  foods  contain  some  material  which  can  be  utilized 
in  building  tissue,  which  is  not  the  case  with  either  whisky 
or  brandy. 

"From  the  above  it  can  readily  be  seen  that  not  only  is 
the  patient  receiving  a  starvation  diet  when  the  physician 
resorts  to  these  preparations,  but  the  unfortunate*  sick  are 
also  compelled  to  pay  exorbitant  prices  for  the  amount  of 
actual  nutritive  matter  received. 

"It  is  urged  in  justification  of  the  use  of  j)rcpanitions 
of  this  class  that  they  contain  constituents  not  found  in 


PEPTONES  111 

our  ordinary  foods  and  in  a  more  perfectly  assimilable  con- 
dition. As  pointed  out  above,  these  so-called  predigested 
foods  contain  no  fats;  the  carbohydrates  in  them  are  the 
ordinary  sugars  present  in  our  common  foods,  while  the 
proteins  belong  to  the  peptone  or  albumose  class.  It  is 
for  these  latter  that  the  greatest  claims  are  made,  but  even 
here  no  value  can  be  pointed  out  not  found  in  whey,  pep- 
tonized full  milk,  or  peptonized  skimmed  milk. 

''There  is  likewise  another  point  of  considerable  impor- 
tance to  consider  in  this  connection.  The  terms  peptone 
and  albumose  include  bodies  of  very  uncertain  composition, 
and  their  suitableness  as  food  substances  depends  largely 
on  how  they  are  prepared.  Animal  experiments  have  shown 
that  nitrogen  equilibrium  may  be  maintained,  for  a  time 
at  least,  by  use  of  enzymic  hydrolytic  products  of  the  pro- 
teins, even  where  the  hydrolysis  has  been  carried  far  beyond 
the  so-called  peptone  stage,  but  it  appears  to  be  Ukewise 
true  that  the  mixtures  secured  by  acid  or  high  temperature 
steam  hydrolysis  have  no  such  value.  Some  of  these,  indeed, 
may  exhibit  a  toxic  behavior.  This  is  true  in  particular  of 
some  of  the  commercial  varieties  of  peptone,  and  until  more 
is  known  of  the  source  of  the  bodies  of  protein  character 
employed  in  the  make-up  of  these  'predigested'  mixtures 
it  is  unwise  to  assume  anything  concerning  the  food  value 
of  the  nitrogen  compounds  found  in  them  by  analysis  or 
even  to  dignify  them  by  the  name  of  foods." 

Dr.  David  L.  Edsall,^  commenting  upon  this  report,  argues 
against  the  use  of  proprietary  foods.  The  development  of 
a  moderate  degree  of  skill  and  resource  in  the  use  of  simple 
and  comparatively  cheap  home  preparations  will  obviate 
any  tendency  to  use  the  proprietary  article.  This  writer 
cites  instances  where  patients  virtually  starved  to  death, 
through  the  mistaken  belief  of  the  physician  that  they  were 
receiving  sufficient  nutrition  from  the  much  vaunted  pro- 
prietary food.     A  very  important   disadvantage   of  these 

1  Journal  of  the  American  Medical  Association,  January  15,  1910. 


112  ARTIFICIAL  FOOD  PREPARATIONS 

foods  is  their  alcohol  content.  This  evil  is  dwelt  upon  in 
the  Council's  report. 

Preparations  from  Vegetable  Protein. — Among  these  we  have: 

Roborat,  obtained  from  grain  seeds,  wheat,  corn,  and 
rice.  It  is  a  fine,  yellow-white,  odorless,  tasteless  powder, 
only  slightly  soluble  in  cold  water.  It  contains  83  per  cent, 
of  vegetable  protein.  This  preparation  is  fairly  well  assimi- 
lated. It  has  been  found  of  value  in  the  treatment  of  ulcus 
ventriculi,  atony,  dilatation,  erosions,  enteritis,  and  chlorosis 
associated  with  gastric  disease.  It  may  also  be  adminis- 
tered as  a  nutritive  enema.  Roborat  may  be  given  in  milk 
or  water. 

Aleuronat  Flour  is  prepared  from  gluten.  It  contains  82 
to  86  per  cent,  of  vegetable  protein;  is  almost  tasteless, 
and  is  insoluble  in  water. 

Mutase  is  a  vegetable  casein  prepared  from  leguminous 
seeds.    It  is  not  expensive. 

Food  Preparations  from  Milk  Protein. — These  preparations 
contain  the  casein  of  milk  and  are  for  the  most  part  useful 
foods. 

Nutrose  is  casein  sodium,  a  white,  odorless,  tasteless  powder 
containing  85  to  90  per  cent,  of  protein.  It  is  soluble  in  warm 
water.  Nutrose  is  almost  completely  absorbed  by  the  small 
intestine.  The  casein  constituent  does  not  give  rise  to 
decomposition  in  the- intestine.  Nutrose  has  been  employed 
in  all  kinds  of  gastro-intestinal  diseases  in  which  a  mild  food 
is  indicated. 

Eucasin,  casein  ammonium,  is  an  odorless,  tasteless 
powder  containing  85  to  90  per  cent,  of  protein;  it  is  soluble 
in  water. 

Sanatogen  contains  95  per  cent,  casein,  5  per  cent,  glycero- 
phosphate of  soda;  the  insoluble  casein  has  been  transformed 
by  the  glycerophosphate  of  soda  into  a  compound  solul^le 
in  water.  Sanatogen  is  well  borne  by  patients  suffering 
from  gastric  ulcer,  gastritis,  or  acute  intestinal  catarrh.  It 
is  particularly  useful  in  the  treatment  of  nervous  diseases 
of  the  stomach.  The  dose  for  adults  is  one  to  three  table- 
spoonfuls  throe  times  a  day.  Like  other  preparations  of 
this  class,  the  chief  l)arrier  to  its  us(^  is  its  cost. 


NUTRITIVE  SUBSTANCES  FROM  EGG  PROTEIN  113 

Plasmon  consists  of  protein  obtained  by  a  mechanical 
process  from  skimmed  milk.  It  is  a  milk-white,  tasteless 
powder  containing  74.5  per  cent,  of  protein.  Plasmon  is 
easily  soluble  in  hot  water,  and  is  almost  completely  absorbed 
in  the  intestine.  Concentrated  solutions  curdle  on  cooling. 
Plasmon  is  useful  in  the  treatment  of  ulcus  ventricuh  and 
intestinal  catarrhs.  It  may  be  taken  in  connection  with 
a  variety  of  foods,  as  plasmon-chocolate,  plasmon-cocoa, 
plasmon-beef.  It  is  a  good  food,  as  well  as  the  cheapest 
of  the  casein  preparations. 

Milk  Somatose  is  prepared  from  the  casein  of  milk,  and 
contains  5  per  cent,  of  tannin  in  chemical  combination. 
It  is  a  yellowish-brown,  odorless,  almost  tasteless  powder, 
soluble  in  hot  water.  Milk-somatose  is  non-irritating,  and 
may  be  employed  with  advantage  in  the  treatment  of 
chronic  intestinal  catarrh;  it  is  likewise  useful  in  the  treat- 
ment of  dysentery  and  intestinal  tuberculosis.  The  dose 
is  four  teaspoonfuls  daily. 

Glohon  is  a  derivative  of  casein  obtained  by  breaking  up 
nucleoprotein  by  means  of  alkalies. 

Galactogen  is  prepared  from  milk;  is  completely  soluble 
and  easily  digested.  It  contains  70  per  cent,  of  protein, 
and  is  agreeable  to  the  taste  and  pleasant  to  take  in  the 
form  of  galactogen-chocolate  (20  to  22  per  cent,  soluble 
protein)  or  galactogen-cocoa  (30  to  32  per  cent,  soluble 
protein) . 

Nutritive  Substances  from  Egg  Protein.  —  Nutritive-Heyden 
is  prepared  from  the  whites  of  fresh  eggs,  and  contains 
90  per  cent,  of  protein.  It  is  a  mixture  of  albumoses  and 
alkaline  albuminates — a  fine  yellowish  powder  which,  un- 
boiled, has  a  somewhat  empyreumatic  odor.  It  is  soluble 
only  in  hot  water.  Heyden's  Nutritive  has  been  employed 
in  chronic  affections  of  the  stomach,  but  is  decidedly  infe- 
rior in  value  to  somatose.  The  dose  is  three  to  four  dessert- 
spoonfuls, in  cocoa,  soup,  or  milk.  It  may  be  given  also 
as  an  enema. 

Protogen  is  a  formaldehyde  protein  prepared  by  the  action 
of  formalin  on  egg  protein.    It  is  not  much  used. 


114  ARTIFICIAL  FOOD  PREPARATIONS 

Preparations  from  Carbohydrates. —  These  preparations  are 
better  adapted  than  protem  compounds  to  increase  the 
nutritive  value  of  certain  foods,  especiallj^  soups,  and  to 
serve  as  subst'tutes  for  ordinar}"  diet. 

Finely  Divided  Flours. — Hartenstein's  legumins  are  fur- 
nished in  foiu-  mixtures: 

I  27  per  cent,  protein;   62  per  cent,  carbohydrates. 

II  21         "  "         68         " 

III  18        "  "        69 

IV  15        "  "        72 

The  leguminous  flours  of  Liebig  and  Timpe  are  recom- 
mended. 

Knorr's  Flours  (oat,  barley,  rice,  bean,  lentil,  pea)  'contain 
7  to  25.0  per  cent,  protein,  57  to  79  per  cent,  carbohydrates. 

The  meals  belonging  to  this  class  are  rolled  oats  and  oat- 
meal, 12.67  per  cent,  protein,  63.8  per  cent,  carbohj'drates. 

The  utihty  of  these  preparations  is  great,  compared  with 
that  of  corresponding  products  in  common  use. 

Dextrinated  Flour. — In  these  flours  the  carbohj^drates  are 
dextrinated.  To  this  group  belong  the  extensive  series  of 
infants'  flours — Carnrick's  lactated,  Ridge's,  Wagner's, 
Mellin's,  Nestle's,  Eskay's,  Allenbury's,  and  Imperial 
Granum.  Owing  to  the  fact  that  it  contains  dextrinated 
starch,  malt  extract  also  belongs  to  this  group.  Malt 
extract  is  a  well-known  product  of  germinating  barley;  it 
contains,  condensed  to  a  syrupy  consistence,  50  to  55  per 
cent,  of  sugar,  of  which  10  to  15  per  cent,  is  dextrinated 
soluble  starch.  The  malt  extracts  of  Lofflund  and  Trommer, 
maltine,  and  malt  beers  have  no  particular  value  as  food 
agents.  The  "double  Braunschweig  Schiffsmumme, "  a 
beverage  containing  more  than  50  per  cent,  of  malt  extract, 
is  of  agreeable  taste,  and  its  calorific  value  is  high. 

Mixed  Nutritive  Preparations.  —  The  preparations  above 
mentioned  contain  not  only  carbohj^drates,  but  also  more 
or  less  protein.  Recently  mixtures  of  carbohydrates  and 
proteins,  the  latter  partially  treated  with  ferments,  have 
been  offered.    Among  such  preparations  we  have: 

Hjjgiama,  consisting  of  condensed  milk,  specially  pre- 
pared cereals,  and  fat-free  cocoa.    It  contains  22.8  per  cent. 


PREPARATIONS  CONTAINING  FAT  115 

protein,  61.6  to  63.32  per  cent,  carbohydrates.  Two  dessert- 
spoonfuls with  one-quarter  liter  of  milk,  three  or  four  times 
a  day,  constitute  the  dose.  Hygiama  tablets  have  been 
manufactured  which  may  be  eaten  without  any  further 
preparation. 

Odda  is  a  mixture  of  yolk  of  egg,  cocoa  fat,  whey,  dex- 
trinated  flour,  and  other  carbohydrates.  It  contains  16.56 
per  cent,  protein  and  18.14  per  cent,  carbohydrates. 

Protem-Milksalt-Cocoa,  a  new  compound  originated  by 
Dr.  O.  Simon,  of  Carlsbad,  and  manufactured  by  Hartwig 
&  A'ogel,  Dresden,  Germany,  belongs  to  this  division.  It 
is  a  cocoa  containing  only  15  per  cent,  of  fat,  combined 
with  37.23  per  cent,  of  protein  predigested  with  ferments, 
and  7.61  per  cent,  of  nutritive  milk  salts.  Up  to  74  per 
cent,  of  the  protein  of  this  cocoa  is  digestible,  and  the  cocoa 
itself  contains  more  digestible  protein  than  an  equal  weight 
of  raw  beef.  The  taste  is  very  pleasant.  This  cocoa  is  par- 
ticularly useful  in  cases  of  chronic  gastric  disease,  especially 
as  its  cost  is  comparatively  low. 

Preparations  Containing  Fat. — RusselVs  Emulsion  contains 
beef  suet,  cocoanut  oil,  peanut  oil,  and  cottonseed  oil,  to 
the  extent  of  42  per  cent,  of  its  volume. 

Nutrole,  manufactured  by  Parke,  Davis  &  Co.,  of  Detroit, 
Michigan,  contains  40  per  cent,  of  mixed  animal  and  vege- 
table oils,  emulsified  with  fresh  eggs. 

Sevetol  (emulsion  sevi  compound,  Wyeth)  is  a  natural 
emulsion  of  mixed  fats  with  proteins  and  carbohydrates. 
The  fats  are  butter  fat,  beef  fat,  oHve  oil,  lard,  and  peanut 
oil;  these  make  up  30  per  cent,  of  the  whole  mixture. 

Cod-liver  Oil  contains  a  considerable  proportion  of  fatty 
acids,  with  bihary  elements.  It  is  converted  bj^  means  of 
the  bile  into  a  very  fine  emulsion,  and  is  most  thoroughly 
absorbed.  Its  taste  is  exceedingly  repugnant.  Cod-liver 
oil  in  elastic  gelatin  capsules  can  sometimes  be  taken  by 
those  who  cannot  take  the  oil  unmasked. 

Oil  of  Sesame  is  more  agreeable  to  the  taste  than  cod- 
liver  oil,  and  cheaper. 


116  ARTIFICIAL  FOOD  PREPARATIONS 

Lipanin  is  a  cod-liver  oil  substitute,  consisting  of  a  mix- 
ture of  94  parts  fine  olive  oil  and  6  parts  oleic  acid.  It  has 
a  pleasant  taste  and  causes  no  subjective  discomforts. 

Mering's  "Kraft"  Chocolate  contains  72.44  per  cent,  fat 
to  which  oleic  acid  has  been  added.  It  is  very  easily  diges- 
tible. 

Milk  Preparations. — Lofflund's  Cream  Conserve  contains 
milk  sugar  and  maltose. 

Vegetable  Milk  is  made  of  nuts  and  milk  of  almonds  (10 
per  cent,  protein,  25  per  cent,  fat,  38.5  per  cent,  sugar). 

Pfund's  Cream  Protein  Mixture  is  a  mixture  of  various 
kinds  of  proteins  with  milk  sugar,  cream,  and  water. 

Gartner's  Fat  Milk  and  VoUmer's  Mother's  Milk  are  fat 
milks  digested  with  pancreatic  juice;  they  are  very  similar 
to  human  milk. 

Kefir  and  Koumiss  are  preparations  of  milk  which  have 
been  subjected  to  fermentation. 

Stimulating  Preparations. — Liebig-Kemmerich's  Meat  Extract 
contains  the  extractives  of  meat,  the  meat  bases  xanthin 
and  kreatinin,  and  inorganic  salts. 

Toril  Meat  Extract,  Beef  Tea,  and  Valentine's  Meat  Juice 
are  less  rich  than  Liebig's  meat  extract. 

Brand's  Essence  of  Beef,  Wyeth's  Meat  Juice,  Fluid  Meat, 
and  Bovril,  much  used  in  England,  contain  smaller  quantities 
of  extractives  than  Liebig's  extract  of  meat. 

Karno  is  less  nutritious  than  Liebig's  extract  of  meat. 

Maggi's  Condiment  is  cheap  and  good.  Maggi's  Bouillon 
is  also  to  be  reconmiended  as  a  stimulating  preparation. 

Composition  and  Relative  Values  of  Meat  Extracts. — The 
Bureau  of  Chemistry  of  the  Department  of  Agriculture,  in 
its  Bulletin  No.  114/  has  given  valuable  data  regarding 
the  commercial  meat  products.  The  preparations  taken  up 
are  divided  into  three  general  classes: 

1.  Solid  and  Fluid  Meat  Extracts. 

2.  Meat  Juices. 

3.  Miscellaneous  Preparations. 

>  Juunuil  of  the  Aiucricun  IMcdicul  Association,  January  23,  IIK)'.),  ji.  31 1. 


COMPOSITION  OF  MEAT  EXTRACTS  117 

Meat  extracts  are  not  to  be  considered  as  foods,  and 
should,  therefore,  not  be  advertised  as  such — a  conclusion 
which  the  government  officials  have  come  to,  and  which 
they  have  stated  as  follows: 

''It  seems  to  be  the  consensus  of  opinion  among  scientific 
investigators  who  have  studied  this  question  that  the  food 
value  of  these  meat  extracts  is  rather  limited,  and  although 
they  are  a  source  of  energy  to  the  body  they  must  not  be 
looked  on  as  representing  in  any  notable  degree  the  food 
value  of  the  beef  or  other  meat  from  which  they  are  derived. 
When  prepared  under  the  best  possible  conditions,  a  com- 
mercial meat  extract  is  of  necessity,  in  order  that  it  may 
not  spoil,  deprived  of  the  greater  part  of  coagulable  proteins, 
which  constitute  the  chief  nutritious  elements  of  the  juice." 

The  physician  should  realize  that  in  prescribing  prepara- 
tions that  have  but  little  food  value  he  may  actually 
starve  the  patient.  According  to  the  high  authority  quoted, 
the  claims  of  the  manufacturers  in  regard  to  the  food  value 
of  ''meat  extracts"  and  "meat  juices"  are  ridiculous.  The 
therapeutic  uses  of  these  preparations  are  therefore  limited. 
It  has  been  claimed  that  such  substances  stimulate  appetite 
and  the  nervous  system.  They  may  stimulate  the  appetite, 
but  their  effects  upon  the  nervous  system  are  open  to 
question.  When  we  order  foods  we  want  foods  and  not 
nerve  stimulants  or  stomachics. 


CHAPTEE    V 

LAVAGE    OF   THE   STOMACH 

Lavage,  or  the  washing  out  of  the  stomach,  is  not  prac- 
ticed nearly  so  often  as  it  was  at  one  time.  Our  knowledge 
of  the  exact  course  of  man}'  diseases  of  the  stomach,  and  of 
the  pathologic  changes  accompanying  them,  has  advanced. 
Lavage  was  formerly  used  in  the  treatment  of  many  con- 
ditions in  which,  with  our  more  accurate  knowledge,  it  has 
been  discarded.  In  ]\Iathieu's  clinic  at  the  Hopital  Andral, 
Paris,  gastric  lavage  is  seldom  performed;  it  is  considered 
sufficient,  instead,  in  the  majority  of  cases,  to  withdraw  the 
contents  of  the  stomach  with  a  stomach  tube  at  inteiwals 
as  indicated  by  the  requirements  of  the  individual  case. 
Boas  says  he  has  occasion  to  wash  out  a  stomach  about 
tmce  a  3'ear. 

Indications. — Lavage  is  always  indicated  in  stenosis  of  the 
pylorus  with  dilatation — in  fact,  in  any  obstruction  of  the 
digestive  tract  which  produces  a  stasis  of  the  stomach 
contents  with  fermentation  and  putrefaction.  Boas  de- 
clares that  he  has  not  had  good  results  in  the  treatment  of 
simple  atony  by  means  of  lavage,  and  advises  against  it  on 
the  ground  that  in  this  condition  we  are  dealing  with  a 
retarded  peristalsis  and  not  with  a  direct  obstacle  to  the 
passage  of  food  into  the  duodenum.  He  feels  that  the 
washing-out  process  not  only  does  not  tend  to  remove 
the  cause,  but  involves  the  danger  of  overdistention  of  the 
relaxed  gastric  walls,  which  is  apt  to  be  harmful. 

In  certain  conditions  lavage  is  of --inestimable  value;  it  is 
indicated: 

1.  In  those  cases  of  poisoning  in  which  the  tube  can  do 
no  damage.  There  is  always  danger  of  perforation  when  the 
poison  has  been  an  escharotic  or  caustic.  In  morphine 
poisoning  the  tube  should  be  used  even  if  the  drug  has  been 


INDICATIONS  1 19 

taken  hypodermicalh^,  since  much  of  the  morphine  injected 
hypodermically  is  found  in  the  stomach  within  an  hour 
after  the  injection. 

2.  In  cases  of  uncontrollable  vomiting,  as  in  intussuscep- 
tion or  intestinal  obstruction.  There  have  been  cases 
reported  in  which  lavage  so  relieved  abdominal  distention 
near  the  obstruction  as  to  result  in  almost  immediate 
recovery.  Stercoraceous  vomiting  always  demands  lavage, 
no  matter  what  the  cause  may  be. 

3.  In  cases  of  gastritis  with  the  production  or  presence 
of  large  quantities  of  mucus. 

4.  In  dilatation,  with  stenosis  of  the  pylorus.  Here  fer- 
mentation and  putrefaction  can  be  inhibited  by  lavage. 
These  are  the  cases  concerning  which  Kussmaul  originally 
called  our  attention  to  the  value  of  stomach  washing. 

5.  In  acute  postoperative  dilatation. 

6.  Before  any  operation  on  the  stomach  or  intestine  is 
performed. 

7.  In  vomiting  following  any  operation  on  the  stomach 
or  intestine. 

8.  To  obviate  postoperative  vomiting  after  an  anesthetic. 

9.  In  intestinal  paresis  following  operation. 

10.  Lavage  with  ice  water  in  hemorrhage  caused  by  gastric 
ulcer  (Ewald).  Lavage,  carefully  applifed,  in  severe  hemor- 
rhage from  gastric  ulcer,  is  the  most  expedient  means  of 
treatment  (Kaufmann). 

11.  In  meteorism  of  typhoid  fever  it  is  frequently  of  great 
benefit. 

12.  In  gastric  tetany. 

13.  In  vomiting  in  cases  of  peritonitis. 

14.  In  acute  gastritis  due  to  improper  eating,  and  in  con- 
vulsions following  overfeeding. 

15.  In  cicatricial  closure  of  the  pylorus,  as  a  palliative 
measure  until  operation  is  performed. 

16.  In  hematemesis  following  stomach  operation,  cau- 
tiously. The  stomach  may  be  distended  with  fluid  and 
blood,  removal  of  which  will  allow  it  to  contract  and  thus 
stop  the  oozing  of  blood  (Mayo). 


120  LAVAGE  OF  THE  STOMACH 

17.  In  diabetes  mellitus  (Sawyer). 

18.  In  selected  cases  of  Bright's  disease  where  urea  is 
being  eliminated  through  the  gastric  mucous  membrane. 

19.  In  eclampsia. 

Contraindications. — Lavage  as  well  as  the  use  of  the  tube 
for  diagnostic  purposes  is  contraindicated : 

1.  In  those  cases  of  gastric  disease,  for  the  most  part 
of  sudden  onset,  which  have  not  attained  any  degree  of 
chronicity  and  where  the  diagnosis  is  apparent  from  the 
symptoms  and  history  of  the  case. 

2.  Where  the  retching  and  vomiting  are  apt  to  offset  any 
good  that  may  be  derived  from  the  use  of  the  tube  either 
for  diagnostic  purposes  or  for  lavage. 

3.  In  marked  prostration,  no  matter  what  the  cause. 

4.  In  broken  compensation  in  heart  disease,  angina  pec- 
toris, or  advanced  degeneration  of  the  heart  muscle,  and  in 
cardiac  neuroses,  aneurism  of  the  aorta,  and  marked  cases  of 
arteriosclerosis. 

5.  In  hemorrhages  of  recent  occurrence,  as  in  apoplexy, 
pulmonary,  renal,  gastric,  and  rectal  hemorrhages. 

6.  In  pulmonary  tuberculosis,  emphysema,  and  severe 
bronchitis. 

7.  In  neurasthenia,  hysteria,  and  epilepsy. 

8.  In  advanced  cachexia. 

9.  In  continued  and  remittent  fever. 

10.  In  pregnancy. 

11.  In  gastric  ulcer  where  hematemesis  has  been  recent 
or  where  blood  has  been  found  in  the  stool;  carcinoma  of 
the  pylorus  accompanied  by  the  classic  symptoms  of  cancer; 
gastric  or  intestinal  diseases  accompanied  by  acute  fever; 
cases  in  which  the  gastric  mucous  membrane  is  easily 
irritated  so  that  bleeding  results  upon  the  passage  of  the 
stomach  tube. 

Any  rules  which  may  be  laid  down  in  regard  to  the  use 
of  the  stomach  tube  are  at  best  but  general.  The  good 
judgment  of  the  physician  must  always  be  his  guide  in 
regard  to  the  indications  and  contraindications  for  the  use 
of  the  stomach  tube,  whether  for  i)uriioscs  of  diagnosis  or 


TECHNIQUE 


121 


for  treatment,  inasmuch  as  there  may  be  other  conditions 
present  which  might  or  might  not  justify  its  use,  in  spite 
of  rules  for  and  against. 

Technique. — Lavage  consists  in  the  washing  out  of  the 
stomach  by  means  of  a  simply  constructed  apparatus — a 
stomach  tube  (Fig.  8,  A)  connected  with  a  funnel  or  glass 

Fig.  8 


Apparatus  for  stomach  lavage:  A,  stomach  tube;   B,  glass  tube;   C,  rubber  tube 
connection;   Z),  glass  irrigator. 

irrigator  {D),  with  a  piece  of  glass  tubing  {B)  between,  a 
connecting  rubber  tube  (C)  being  attached  at  one  end  to  the 
glass  and  at  the  other  to  the  irrigator.  Jacques  tubes, 
made  of  soft  red  rubber,  are  now  universally  employed. 
The  stomach  tube  (Fig.  9)  should  have  two  lateral  oval 
openings  near  the  point ;  and  the  point  should  be  solid  and 
closed  to  prevent  the  collection  of  material  below  the  open- 


122 


LAVAGE  OF  THE  STOMACH 


ings.  The  edges,  of  the  openings  should  be  smooth  and 
rounded,  since  otherwise  particles  of  mucous  membrane 
may  be  caught  and  torn  off.  The  tubes  for  adults  should 
be  large,  averaging  Nos.  32  to  34. ^    The  funnel  of  the  lavage 


Fig.  9 


Stomach  tube  showing  elongated  lateral  openings. 

apparatus  (Fig.  10)  should  have  a  capacity  of  one-half  to 
one  liter.  The  small  end  of  the  funnel  must  be  large  enough 
to  permit  the  passage  of  food.  The  rubber  connecting  tube 
must  be  of  the  same  calibre  as  the  stomach  tube,  and  long 


Fig.  10 


.Stoinaeli  tube  .showing  funnel  connections. 

enough  to  reach  from  the  patient's  mouth  to  the  floor  of 
the  room.     A  large  glass  irrigator  is  probably  better  than 

•  Some  confusion  has  resulted  from  the  fact  tliat  there  are  three  standards 
of  measurement,  the  American,  English,  and  French.  To  obviate  error  the 
American  Surgical  Trade  Association  has  adopted  the  French  standard;  so 
figures  designating  the  sizes  of  tubes  will  be  in  the  French  or  standard  metric 
scale. 


TECHNIQUE  123 

the  glass  funnel;  its  capacity  should  be  at  least  1500  Cc. 
The  irrigator  is  provided  with  a  handle,  and  has  a  hole  near 
the  brim  by  which  it  may  be  suspended  on  a  hook.  The 
lower  or  outflow  opening  should  correspond  in  diameter  to 
the  calibre  of  the  stomach  tube. 

Lavage  with  this  simple  apparatus  is  accomplished  as 
follows:  The  patient  should  be  impressed  by  his  physician 
with  the  necessity  of  the  washing-out  process.  He  should 
be  seated  in  a  comfortable  position,  with  the  body  inclined 
slightly  forward,  and  instructed  to  breathe  regularly  and 
deeply.  He  is  taught  to  make  energetic  movements  of 
swallowing  at  the  command  ''swallow."  Artificial  teeth 
should  be  removed  before  lavage  is  begun.  The  patient's 
hands  may  be  employed  in  holding  a  pus  basin  or  other 
receptacle  for  the  purpose  of  cleanliness,  and  in  this 
way  any  interference  on  his  part  may  be  obviated.  The 
stomach  tube  should  be  moistened  with  water,  not  oil,  and 
directed  over  the  dorsum  of  the  tongue.  When  the  end  of 
the  tube  reaches  the  posterior  pharyngeal  wall,  deglutition 
begins.  The  tube  slides  easily  over  the  cricoid  cartilage 
into  the  first  section  of  the  esophagus.  When  this  point  is 
reached  it  is  easy  to  pass  the  tube  on  into  the  stomach. 
(The  slight  irritation  effected  by  moving  the  tube  up  and 
down  is  sufficient  to  cause  the  evacuation  of  large  quanti- 
ties of  stomach  contents,  especially  if  aided  by  pressure  on 
the  abdominal  muscles  on  the  part  of  the  patient.)  The 
irrigator  or  funnel,  held  low,  should  be  filled  by  an  assistant 
with  500  Cc.  of  lukewarm  water.  The  tube  of  the  irrigator  is 
meanwhile  stopped  by  means  of  the  fingers  or  clamp  at  a 
short  distance  from  the  free  end,  and  connection  duly  made 
with  the  glass  joint  and  the  stomach  tube  in  position.  The 
irrigator  is  then  raised  until  nearly  the  whole  quantity  of 
water  has  passed  into  the  patient's  stomach.  A  small  quantity 
of  water  should  be  left  in  the  irrigator  to  prevent  the  entrance 
of  air  into  the  tube.  The  irrigator  is  now  lowered  to  the 
floor  of  the  room,  so  that  the  stomach  contents,  including 
the  water,  may  be  siphoned  off.  It  should  be  held  in  such 
a  manner  that  the  outflowing  liquid  may  be  visible.     After 


124  LAVAGE  OF  THE  STOMACH 

noting  the  difference  between  the  outflowdng  fluid  and  the 
clear  water  that  entered  the  stomach,  the  contents  of  the 
irrigator  may  be  emptied  in  a  convenient  receptacle.  ]\Iore 
water  is  allowed  to  enter  the  stomach,  and  the  process  of 
lavage  continues  by  alternately  raising  and  lowering  the  irri- 
gator until  the  water  comes  from  the  stomach  clear.  When 
lavage  has  been  completed  the  stomach  tube  should  be  de- 
tached from  the  irrigator  and  rapidly  and  gently  withdrawn 
from  the  patient's  stomach.  It  is  important  to  disconnect 
the  irrigator  and  tube;  otherwise,  -wdth  the  former  resting 
on  the  floor,  suction  produced  bj'  the  siphon  effect  would 
tend  to  invaginate  the  mucous  Hning  of  the  stomach  into 
the  lateral  openings  of  the  tube  and  thereby  injure  the 
stomach  wall. 

In  the  absence  of  an  assistant-,  the  physician  should  fill 
the  irrigator  with  the  required  quantity  of  water  before 
commencing  the  operation.  In  order  to  keep  the  tube  of 
the  irrigator  free  from  air,  it  should  be  compressed  by  means 
of  a  large  tube  compressor  near  the  glass  connection  after 
being  filled  with  the  water  to  this  point.  The  introduction 
of  the  stomach  tube  follow^s.  The  patient  is  du-ected  to  keep 
the  tube  steady  \\dth  one  hand  at  his  mouth,  while  with  the 
other  he  holds  the  basin.  With  the  irrigator  resting  on  the 
floor,  the  physician  may  connect  it  with  the  stomach  tube, 
loosen  the  tube  clamp  or  compressor,  and  elevate  the 
irrigator. 

Patients  to  whom  stomach  lavage  must  be  administered 
regularly  and  over  a  long  period  of  time  can  be  taught  to 
carry  out  the  operation  without  the  aid  of  a  physician. 
Autolavage  is  a  form  of  stomach  irrigation  which  has  been 
called  physiologic  in  order  to  distinguish  it  from  the  kind 
I  have  just  described;  for  this  the  use  of  the  stomach  tube 
is  not  necessary.  It  is  sufficient  that  the  patient  drink 
four  to  eight  ounces  of  the  irrigating  fluid  and  then  lie 
down  on  his  abdomen,  supported  on  a  somewhat  hard, 
resisting  surface,  across  the  bed  or  on  the  floor.  In  this 
position  let  him  breathe  as  deeply  as  possible.  Fifteen  to 
twenty  deep  respirations  are  sufficient  to  drive  the  contents 


TECHNIQUE  125 

of  the  stomach  through  the  pylorus.  This  procedure  may 
be  repeated  as  often  as  necessary.  As  a  rule,  the  patient 
may  rest  on  his  abdomen  for  five  minutes,  taking  from  time 
to  time  a  number  of  deep  respirations.  It  has  been  proved 
that  in  this  way  the  stomach  may  be  cleansed  quite  as 
effectively  as  by  the  introduction  of  the  stomach  tube, 
provided  the  pylorus  be  not  occluded.  This  method  has 
a  considerable  advantage  over  the  other,  for  by  it  the 
nourishment,  as  prepared  by  the  stomach,  is  not  lost,  but 
follows  the  physiologic  path.  Besides,  the  patient  will 
submit  much  more  readily  to  it  than  to  the  manipulation 
of  the  stomach  tube.  In  order  to  obtain  the  maximum 
effect  from  this  method  of  autolavage,  we  must  strive  by 
all  means  at  our  command  to  free  the  pylorus  from  all 
obstacles  that  interfere  with  its  proper  function.  This  is 
partially  achieved  by  administering  the  fluid  lukewarm. 

Some  patients  may  be  taught  to  use  the  stomach  tube 
themselves  with  the  aid  of  some  member  of  the  household. 
None  but  the  best  apparatus  should  be  employed.  After 
use  it  should  be  thoroughly  cleansed  by  means  of  hot  water. 
In  lavage,  whether  the  patient  uses  the  apparatus  without 
the  aid  of  the  physician,  or  whether  the  physician  performs 
the  operation  upon  a  passive  patient,  the  simple  apparatus 
described  will  be  found  adequate  for  all  purposes. 

Fig.  11  illustrates  the  apparatus  designed  by  Friedlieb 
on  the  principle  of  suction.  This  instrument  was  designed 
to  facilitate  the  removal  of  obstructing  particles  from 
the  stomach  tube  by  aspiration  by  means  of  a  rubber 
bulb.  The  apparatus  of  Strauss  (Fig.  12)  accomplishes  the 
same  purpose  by  means  of  a  double  bulb.  Both  these 
instruments,  in  the  opinion  of  the  author,  are  unnecessary, 
inasmuch  as  clogging  of  the  tube  may  be  prevented  by 
raising  the  irrigator  of  the  apparatus  described,  and  thus 
forcing  the  tube  clear  by  water  pressure. 

In  cases  where  the  stomach  is  greatly  dilated  it  is  fre- 
quently impossible  to  wash  it  out  at  one  sitting.  In  such 
cases  lavage  may  be  better  accomplished  with  the  patient 
in   a  recumbent  posture.     With   the  patient   seated,  the 


126 


LAVAGE  OF  THE  STOMACH 


thoroughness  of  lavage  may  be  promoted  by  pressmg  or 
kneading  the  hypogastric  region  after  the  water  has  been 
introduced  into  the  stomach. 

In  cases  where,  owing  to  irritabihty  of  the  fauces,  it 
seems  impossible  to  introduce  the  stomach  tube,  the  difficulty 
may  be  overcome  by  painting  the  fauces  with  a  5-per-cent. 


Fig.  U 


Stomach  tube  with  suction  bulb.      (Friedlieb.) 

solution  of  cocaine  or  beta-eucaine.  Another  effective  and 
entirely  safe  method  of  preventing  nausea  from  the  intro- 
duction of  the  stomach  tube  is  to  freeze  two  or  three  inches 
of  the  extremity  of  the  tube  just  before  introducing  it,  the 
object  being  to  secure  light  temporary  anesthesia  of  the 
fauces  and  pharynx  by  means  of  the  cold  rubber.     In  tliis 


TECHNIQUE 


127 


way  cold  is  applied  exactly  where  anesthesia  is  needed,  and 
the  irritability  is  overcome.  Thus  the  tube  may  be  intro- 
duced for  the  first  time  with  practically  no  gagging,  strain- 
ing, or  nausea.  The  extremity  of  the  tube  may  be  frozen 
by  a  few  moments'  spraying  with  ethyl  chloride.  The  tube, 
of  course,  may  be  chilled  in  other  ways,  but  the  ethyl 
chloride  is  convenient  and  efficient.  The  tube  has  been  found 
not  to  stiffen  markedly  under  the  influence  of  the  extreme 
cold,  so  that  no  trauma  from  the  frozen  rubber  occurs. 
By  the  time  the  tube  reaches  the  cardia  its  low  temperature 
is  suflSciently  modified  to  obviate  danger  to  the  gastric 
mucosa,  even  though  it  be  allowed  to  remain  in  the  stomach 
for  some  time. 

Fig.  12 


Suction  tube  with  double  bulb.      (Strauss.) 

The  process  of  washing  out  the  stomach  is  not  attended 
with  any  danger.  Temporary  cessation  of  respiration  of 
reflex  origin  occurs  in  many  patients  at  the  first  introduction 
of  the  tube.  This,  however,  should  not  occasion  anxiety  on 
the  part  of  the  physician,  since  it  usually  passes  off  readily. 
Should  the  patient  become  alarmed  and  attempt  to  pull 
out  the  tube,  an  emphatic  request  to  ''breathe  deeply"  will 
overcome  his  fears  and  make  possible  the  complete  intro- 


128  LAVAGE  OF  THE  STOMACH 

duction  of  the  tube.  Where  paroxysms  of  cough,  severe 
and  protracted,  supervene,  the  operation  of  lavage  should 
be  interrupted  before  completion. 

Hemorrhages  occasionally  occur,  especially  in  cases  of 
carcinoma  and  ulcer.  In  the  presence  of  such  symptoms 
lavage  would  be  contraindicated.  Lavage  is  rarely  employed 
in  cases  of  cancer  of  the  stomach  except  as  a  palhative 
measure  in  obstruction  of  the  pylorus.  In  gastric  ulcer  it 
is  apt  to  do  a  great  deal  of  harm,  and  should  never  be  em- 
ployed when  there  is  any  indication  of  gastric  hemorrhage. 
In  cases  of  nervous  dyspepsia  lavage  sometimes  transforms 
the  patient  into  a  gastric  hypochondriac,  a  most  lamentable 
condition.  In  the  majority  of  nervous  cases  lavage  is 
contraindicated.  Surface  hemorrhage  may  take  place  in 
catarrh  due  to  gastritis;  when  such  hemorrhages  are  of  a 
pronounced  character  the  irrigations  should  be  discontinued. 

According  to  Musser,  not  over  5  per  cent,  of  cases  of 
gastric  disease,  or  of  patients  presenting  symptoms  sug- 
gestive of  gastric  disease,  require  lavage  as  an  element  of 
the  treatment.  In  the  earher  periods  of  practice,  gastro- 
enterologists  resorted  to  lavage  much  more  frequently  than 
at  the  present  time. 

Gastroenterologists  differ  in  their  views  regarding  the  time 
stomach  irrigations  should  be  administered.  I  consider  it 
advisable  in  cases  where  there  is  no  engorgement,  for  ex- 
ample in  cases  of  chronic  gastritis,  when  we  wish  to  remove 
mucous  secretion,  to  perform  irrigation  in  the  morning  while 
the  stomach  is  empty.  In  cases  of  stenosis  of  the  pylorus, 
with  stagnant  masses  of  food  in  the  stomach,  the  best  time 
for  lavage  is  in  the  evening  shortly  before  the  evening  meal. 

The  duration  of  the  treatment  must  be  determined  in 
each  case  by  the  conditions  present.  In  cases  where  it  is 
impossible  to  determine  this  point,  as  in  inoperable  car- 
cinoma, it  is  advisable  to  have  the  patient  wash  out  his 
own  stomach.  A  medicated  lavage  may  follow  the  cleansing 
lavage.  The  indications  for  the  different  kinds  of  lavage  are 
given  under  the  respective  diseases. 

In  lavage  preliminary  to  surgical  operation  on  the  stomach, 


THE  STOMACH  DOUCHE  129 

care  should  be  exercised  that  no  water  remains  in  the  viscus. 
In  lavage  kept  up,  as  described,  until  the  washings  return 
clear,  a  further  quantity  of  water  can  be  dislodged  by  placing 
the  patient  in  the  Trendelenburg  position ;  the  flow  will  con- 
tinue until  the  tube  is  withdrawn  from  the  cardiac  orifice, 
when  the  stomach  will  be  entirely  emptied.  C.  Neck  re- 
ported that  experiments  on  the  cadaver  showed  that  when 
the  operation  of  lavage  was  performed  in  the  ordinary  way 
a  little  pool  was  always  left  behind,  but  on  the  change  of 
position  this  gravitated  to  the  cardia  and  could  then  be 
aspirated  by  slowly  pulling  the  tube  out  at  the  mouth,  the 
tip  being  kept  in  the  fluid. 


THE  STOMACH  DOUCHE 

Douching  of  the  stomach  should  be  employed  only  when 
the  viscus  is  empty.  The  sole  object  is  to  irrigate  the  mucous 
membrane,  either  with  plain  water  or  with  medicated  solu- 
tions. The  douching  may  be  performed  by  means  of  Rosen- 
heim's tube  (Fig.  13).    This  instrument  consists  of  a  stomach 

Fig.  13 


^~J  \^  ^^ <^ 


_r^ r\         r\ r^ rv 


Perforated  tube.      (Rosenheim.) 

tube  having  at  its  gastric  extremity  a  number  of  small 
openings  from  one  to  two  millimeters  in  diameter.  Water  is 
permitted  to  flow  through  the  tube  into  the  stomach  so 
that  all  parts  of  the  gastric  mucosa  are  irrigated  through 
the  numerous  small  openings.  The  process  is  frequently 
impeded,  owing  to  the  blocking  of  the  fenestra  by  mucus. 
The  method  of  Richter,  designed  to  remove  mucus  by 
means  of  irrigation,  consists  of  stomach  douching.  The 
ordinary  stomach  tube  is  introduced  to  the  extent  of  40 
centimeters,  or  to  the  cardia  of  the  empty  stomach.  The 
irrigating  fluid  under  pressure  is  allowed  to  pour  into  the 
9 


130 


LAVAGE  OF  THE  STOMACH 


viscus  SO  as  to  douche  the  collapsed  walls.    While  a  small 
quantity  of  water  yet  remains  in  the  irrigator  the  tube  is 


Fig.  14 


Apparatus  for  stomach  douche  (Einhorn):    A,  stomach  tube;   B,  hard  rubber  capsule; 
C,  aluminum  ball. 

pushed   into   the    stomach    so   that    the   fenestras   become 
immersed  in  the  water  there;  the  irrigator  is  then  lowered 


THE  STOMACH  DOUCHE  131 

to  the  floor  and  the  contents  are  siphoned  out.  The  tube 
is  then  withdrawn  to  the  cardia,  and  the  process  is  repeated 
as  often  as  necessary  to  cleanse  the  stomach  of  the  mucous 
secretion. 

Einhorn's  apparatus  (Fig.  14)  consists  of  a  tube  {A) 
about  60  Cm.  in  length  and  1  Cm.  in  diameter,  having  at 
the  gastric  extremity  an  oval  piece  of  hard  rubber  shaped 
like  a  capsule  {B).  This  capsule  has  numerous  minute 
openings,  and  at  the  lower  end  a  larger  round  aperture. 
Within  the  hard  rubber  capsule  is  an  aluminum  ball  {€), 
which  acts  as  a  valve  and  closes  the  opening  in  the  extremity 
of  the  capsule  when  the  tube  is  introduced  and  the  irrigation 
fluid  forced  into  it.  The  water  enters  the  stomach  by  way 
of  the  small  openings.  The  outflow,  however,  forces  the  ball 
from  the  lower  opening,  and  the  entering  liquid  keeps  this 
opening  clear  until  the  stomach  is  completely  emptied.  The 
defects  of  the  Rosenheim  tube  are  remedied  in  Einhorn's 
apparatus.  Preparatory  to  the  entrance  of  the  irrigating 
fluid,  Einhorn's  tube  should  be  introduced  only  a  short 
distance  below  the  cardia;  but  to  facilitate  the  return  flow 
of  water  and  mucus,  it  should  be  pushed  in  10  to  12  Cm. 
farther. 

Turck  has  devised  a  double-flow  stomach  douche,  con- 
sisting of  two  tubes  cemented  together;  one  tube  is  longer 
than  the  other,  which  enables  it  to  reach  the  fundus  while 
the  shorter  tube  is  near  the  cardia.  The  latter  has  at  its 
end  a  metal  ball,  finely  perforated;  the  water  passing  through 
acts  as  a  fine  needle  spray  or  douche  on  the  mucous  mem- 
brane of  the  stomach.  The  longer  tube  carries  the  water 
back,  so  that  the  stomach  is  not  distended  with  too  great 
a  quantity  of  water  at  any  one  time. 

Chase  has  devised  an  improved  tube  (Fig.  15),  by  means 
of  which  (1)  the  gastric  contents  can  be  removed  by  aspira- 
tion; (2)  the  stomach  washed  or  douched;  (3)  and  inflation 
of  the  stomach  effected  without  making  a  connection  or 
disconnection  of  the  apparatus  and  without  the  use  of 
stopcock  or  shut-off.  By  substituting  a  ^'Rosenheim" 
douching   tube  the   stomach   may  be   douched   as  recom- 


132 


LAVAGE  OF  THE  STOMACH 


mended  by  Rosenheim.  Chase's  apparatus,  shown  in  the 
cut,  consists  of  (1)  an  Ewald  stomach  tube  proper,  30  inches 
long,  marked  at  22  inches  from  its  distal  end  \\dth  a  white 
band;   (2)   an  adjustable  sahva  shield,  to   prevent   saliva 


Fig.  15 


Stomach  tube.      (Chase.) 

from  flowing  down  the  tube;  (3)  a  glass  connector;  and 
(4)  a  30-inch  connecting  tube,  to  which  is  attached  a  strong 
valveless  bulb  of  3  ounces  (90  Cc.)  capacity. 

Too  much  should  not  be  expected  of  the  stomach  douche. 
It  is  rarely  employed  as  a  therapeutic  measure,  and  very 
often  any  efficacy  it  may  possess  is  due  to  the  mental 
impression  made  upon  the  patient. 


CHAPTER    VI 

MASSAGE— ELECTRICITY 
MASSAGE  OF  THE   STOMACH 

Massage  consists  of  a  systematic  manipulation  of  the 
stomach  for  definite  therapeutic  ends.  The  success  of  the 
process  depends  upon  the  precise  performance  of  certain 
well  understood  movements  of  the  hands  of  the  physician. 
The  operator  in  applying  the  treatment  should  keep  in 
mind  the  particular  end  to  be  accomplished  in  the  individual 
patient.  The  several  movements  consist  of  various  appli- 
cations of  rubbing,  kneading,  stretching,  and  pinching  of 
the  muscles.  The  two  hands  must  be  directed  with  intelli- 
gence and  skill. 

Indications. — Massage  is  of  greatest  value  in  diseases  due 
to  altered  metabohsm,  and  in  those  in  which  the  powers  of 
digestion,  absorption,  or  assiixiilation  are  defective.  Nutri- 
tion may  be  profoundly  influenced  by  regular  and  continued 
massage.  Among  the  special  indications  for  this  mechanical 
treatment  are: 

1.  Inert  musculature,  which  may  be  strengthened  by 
passive  exercise,  and  connective-tissue  adhesions  that  require 
to  be  relaxed  or  broken  up. 

2.  Retention  of  gastric  contents  for  an  abnormally  long  time 
in  the  alimentary  tract.  This  applies  more  particularly  to  the 
intestine  than  to  the  stomach,  where  under  some  conditions 
mechanical  treatment  may  cause  direct  injury. 

3.  In  certain  forms  of  dilatation  due  to  pyloric  stenosis. 
Zabludowski  has  reported  good  results  in  such  conditions. 
However,  in  the  presence  of  marked  fermentative  processes 
massage  should  not  be  employed,  owing  to  the  possibility 
of  propelling  fermenting  masses  into  the  intestine,  where  the 


134  MASSAGE— ELECTRICITY 

conditions  for  the  gro'«i:h  and  multiplication  of  bacteria 
are  much  more  favorable  than  in  the  stomach. 

4.  In  certain  sensory  forms  of  nervous  dyspepsia,  where 
sensations  of  pressure  or  pain  are  present,  massage  may  be 
tentatively  employed. 

5.  The  mechanical  treatment  has  given  favorable  results 
in  cases  of  primary  intestinal  atony  tending  to  secondary 
disturbances  of  the  gastric  function. 

Contraindications. — Massage,  according  to  Boas,  is  contra- 
indicated  in  all  recent  cases  of  ulcer  with  adhesions,  in  which 
cases  even  its  cautious  application  may  cause  a  perforation 
of  the  ulcer  into  a  neighboring  organ,  \^dth  the  well-known 
disastrous  effects.  It  should  not  be  employed  in  any  residual 
inflammatory  conditions  of  the  gastro-intestinal  tract,  nor 
in  the  acute  inflammatory  stage  in  which  there  are  symp- 
toms of  meteorism  or  fever.  It  should  be  avoided  in  the 
presence  of  abdominal  pain.  Patients  with  hyperchlorhy- 
dria  or  hypersecretion  are  not  to  be  subjected  to  massage, 
owing  to  the  danger  of  inducing  ulcer  of  the  stomach.  Boas 
also  considers  massage  to  be  contraindicated  in  atonic  con- 
ditions of  the  stomach  in  which  dilatation  and  organic 
stenosis  are  present.  Zabludowski  states  that  '4f  the 
gastric  muscles  are  spontaneously  very  active,  if  the  peri- 
staltic movements  are  pronounced  and  frequent  or  some- 
times as  if  in  a  tetanic  condition,  and  if  the  stomach  felt 
by  the  hand  feels  somewhat  as  a  contracted  uterus  after 
birth,"  the  massage  treatment  should  not  be  employed. 

Carcinomata  of  the  stomach  are  always  absolute  contra- 
indications for  massage,  owing  to  the  possibility  of  exciting 
to  rapid  growth  a  tumor  that  has  hitherto  been  latent. 
Boas  advises  against  the  use  of  massage  in  the  treatment 
of  patients  above  forty  years  of  age  in  whom  the  symptoms 
of  gastric  disease  have  appeared  suddenly,  unless  mahg- 
nancy  can  be  positively  excluded.  He  states  further  that 
inconsiderate  massage  of  the  abdomen  may  stimulate  a 
latent  intestinal  cancer  to  rapid  growth  and  metastasis. 
Dormant  gastric  ulcers  may  be  awakened  by  massage  to 
harmful  activity.     Whenever  the  test  for  occult  blood  in 


MASSAGE  OF  THE  STOMACH  135 

the  feces  is  positive,  massage  is  contraindicated.  It  is  im- 
portant to  examine  McBurney's  point  and  the  region  of 
the  gall-bladder  before  attempting  massage  of  the  abdomen. 
Boas  notes  that  a  history  of  gastralgia  at  any  time,  espe- 
cially before  or  after  pregnancy,  increases  the  probability  of 
latent  gallstone  disease,  contraindicating  massage.  There 
are  various  affections  of  the  liver,  spleen,  and  pancreas  which 
contraindicate  abdominal  massage.  In  fact,  pain  of  any 
kind  contraindicates  it. 

Massage  may  be  apphed  when  the  stomach  is  either 
full  or  empty.  When  the  stomach  is  filled,  massage  is  indi- 
cated in  cases  of  spasm  of  the  pylorus  and  in  mild  cases  of 
organic  stenosis,  the  purpose  being  to  propel  the  macerated 
food  into  the  intestine.  It  should  be  performed  three  or 
four  hours  after  the  chief  meal. 

Technique. — The  technique  of  the  mechanical  treatment 
must  vary  according  to  the  object  to  be  accomphshed. 
When  the  object  is  passive  evacuation  of  the  stomach 
contents  through  the  pylorus,  Zabludowski  advises  inserting 
the  right  hand  deeply  in  the  loose  flesh  on  the  left  side, 
grasping  a  portion  of  the  stomach  between  the  thumb  and 
the  four  fingers,  and  by  a  pushing  motion  at  the  fold  mov- 
ing the  gastric  contents  toward  the  pylorus.  The  left  hand 
advances  toward  the  pyloric  exit,  beginning  near  the  thumb 
of  the  right  hand.  The  patient  should  be  lying  in  a  slanting 
position,  the  body  sloping  toward  the  right  side.  These 
movements  on  the  part  of  the  physician  should  be  repeated 
as  often  as  necessary.  The  massage  movements  on  the  full 
stomach  should  be  concluded  by  short  tapping  strokes, 
technically  known  as  tapotement.  Both  hands  of  the  oper- 
ator are  placed  vertically,  midway  between  supination  and 
pronation,  over  the  part  to  be  treated;  they  are  then 
completely  supinated  and  the  stomach  is  tapped  with 
the  fingers  widely  separated.  The  movements  should  be 
executed  rapidly,  but  too  great  force  should  be  avoided. 
Tapotement,  as  it  is  called,  has  a  stimulating  effect  upon 
the  musculature  of  the  stomach. 

Zabludowski  performs  petrissage  in  the  following  manner: 


136  MASSAGE— ELECTRICITY 

The  operator  stands  at  the  right  side  of  the  patient  and 
presses  with  the  right  hand  in  the  gastric  region  in  the  middle 
hne.  The  pressure  is  deep,  so  as  to  reach  the  spinal  column, 
therebj^  dividing  the  stomach  into  two  equal  parts — one 
the  fundus,  the  other  the  p^'lorus.  The  food  mixture  com- 
pressed in  the  pyloric  half  is  then  to  be  pushed  toward 
the  pylorus  so  that  it  may  act  somewhat  like  a  bougie, 
dilating  the  pyloric  exit. 

According  to  Gustaf  Nortrom,  on  account  of  the  deep 
situation  of  the  stomach  and  the  shght  resistance  of  the 
deep  plane  on  which  it  rests,  only  a  hmited  portion  of  the 
viscus  can  be  reached  in  the  dorsal  decubitus.  For  dilated 
stomach  the  author  kneads  at  first  from  left  to  right  with 
patient  on  back,  knees  bent  and  head  raised.  After  a 
few  minutes  he  has  the  patient  he  on  the  right  side,  and 
petrissage  is  performed  ^dth  both  hands  alternately,  from 
pylorus  toward  cardia.  Gentleness  is  necessary  during  the 
seance.  The  operation  should  last  about  fifteen  minutes  for 
the  stomach  alone,  and  fifteen  minutes  more  for  the  intes- 
tine if  there  is  constipation.  The  treatment  should  be 
given  two  or  three  hours  after  a  meal.  The  beneficial  effect 
most  frequently  manifests  itself  first  by  a  returning  appetite, 
then  by  the  disappearance  of  the  rumblings,  eructations, 
gastric  pains,  headache,  vertigo,  etc.  At  the  beginning  the 
diet  must  be  light  and  limited  in  quantit3^  Besides  dila- 
tation of  the  stomach,  massage  is  of  benefit  in  chronic 
gastritis,  nervous  dyspepsia,  gastralgia  due  to  nem-asthenia 
or  anemia,  and  pylorospasm,  but  it  may  do  harm  in  ulcers 
or  tumors  of  the  pylorus.  The  massage  movements  are  not 
always  successful  in  expelling  the  contents  of  the  stomach 
into  the  duodenum. 

Hemmeter  gives  the  following  directions  for  improving 
the  tone  of  the  empty  stomach: 

"The  masseur  places  himself  to  the  right  of  the  patient, 
who  should  lie  on  his  back  with  knees  slightly  flexed. 

"First  movement:  («)  Insert  the  left  hand,  slowly  and 
gradually,  deeply  under  the  left  arch  of  the  false  ribs,  under 
and  past  the  edge.    To  increase  the  pressure,  gently  press 


MASSAGE  OF  THE  STOMACH  137 

the  right  hand  firmly  on  the  left.  Second  movement:  (b) 
Now  describe  small  circles  with  the  hands  thus  arranged, 
proceeding  slowly  from  the  pylorus  to  the  fundus.  Third 
movement:  (c)  Perform  strong  vibratory  movements 
toward  the  depth  with  the  finger  tips  while  a  and  b  are 
being  executed.  Fourth  movement:  (d)  Knead  the  stom- 
ach between  the  thumb  and  four  fingers,  and  in  conclusion 
execute  stroking  passes,  with  extended  four  fingers,  from 
left  to  right." 

Crede's  method  may  be  applied.  This  well-known  process 
is  employed  frequently  in  the  expression  of  the  placenta, 
the  placenta  being  expelled  in  the  same  manner  that  a  stone 
is  removed  from  a  cherry.  The  method  is  an  attempt,  by 
performing  the  expression  movement  transversely  in  the  line 
of  the  transverse  axis  of  the  stomach,  to  propel  the  stomach 
contents  into  the  duodenum. 

Massage  movements  may  be  facilitated  by  lubricating 
the  epigastric  region  with  pure  olive  oil  or  with  glycerin. 
By  the  use  of  glycerin,  oily  stains  on  the  clothing  may  be 
avoided.  One-per-cent.  salicylic  acid  added  to  the  glycerin 
will  prevent  irritation  of  the  skin. 

Wegele  recommends  the  employment  of  drugs  in  con- 
junction with  massage  in  various  forms  of  chronic  gastritis 
and  in  hyperacidity,  for  hyperesthesia  of  the  mucous  mem- 
brane, and  for  nervous  gastralgia.  The  medication  he  em- 
ploys consists  of  physiologic  salt  solution;  1-per-cent.  solution 
of  ichthyol;  1.5-per-cent.  Carlsbad  salt  solution;  5  to  6  per 
cent,  suspension  of  bismuth  subnitrate;  1  to  2  per  cent, 
silver  nitrate  solution,  followed  by  rinsing  with  normal 
saline  solution;  decoctions  of  bitter  tonics;  and  disinfecting 
solutions.  The  fluids  are  either  swallowed  or  introduced  by 
means  of  the  stomach  tube. 

Massage  of  the  stomach  should  never  be  delegated  to  a 
layman  to  perform,  nor  should  it  be  undertaken  by  anyone 
who  is  not  thoroughly  conversant  with  the  principles  of  the 
treatment. 

Vibratory  massage  is  of  little  or  no  value  in  the  treatment 
of  diseases  of  the  stomach.     It  is  of  value  in  neurasthenic 


138  MASSAGE— ELECTRICITY 

conditions,  where  it  should  be  applied  to  the  spine.  It 
should  never  be  used  directly  on  the  stomach  in  any  dis- 
eased condition  of  that  viscus.  Pilgrim  maintains  that  he 
can  relax  the  pylorus  b}^  applying  vibratory  massage  over 
the  twelfth  dorsal  vertebra. 

John  K.  Mitchell^  maintains  that  in  chronic  constipation 
by  careful,  continued,  and  frequently  repeated  massage  of 
the  intestine  the  bowel  may  be  emptied,  the  weakened  intes- 
tinal muscles  stimulated,  and  the  secretions — nearly  always 
deficient  in  this  disease — brought  back  in  normal  quantity; 
and  when  the  patients  have  begun  to  improve  a  careful  and 
punctual  habit  of  defecation  may  be  inculcated  and  a  per- 
manent cure  thus  result.  Before  attempting  to  use  massage 
for  chronic  constipation  it  is  necessary  to  empty  the  bowels 
thoroughly  by  high  enemata,  lest  there  be  some  retention  of 
feces  in  the  colon,  which  sometimes  happens  even  when  the 
bowels  are  being  moved  reasonably  well  daily  by  means  of 
purgatives.  Should  abdominal  massage  be  apphed  while 
these  impacted  masses  are  in  the  bowel,  inflammator}^  dis- 
turbances might  result. 


ELECTRIC   TREATMENT   OF   THE   STOMACH 

The  use  of  electricity  in  the  treatment  of  stomach  dis- 
orders has  been  highly  recommended  by  various  writers, 
but  the  general  practitioner  rarely  avails  himself  of  this 
important  therapeutic  agent.  Thomas  G.  Ashton  states  that 
in  electricity  we  possess  an  important  and  often  efficient 
means  of  treating  chronic  gastritis,  and  that  direct  elec- 
trization of  the  stomach  is  not  only  an  important  means  of 
combating  nervous  disorders  of  that  organ,  but  is  also  of 
service  in  gastric  affections  having  an  organic  basis. 

To  Einhorn  belongs  the  credit  of  bringing  electrization 
of  the  stomach  within  the  range  of  practical  therapeutics, 
both  by  experiment  and  by  the  invention  of  his  deglutible 

1  Journal  of  the  American  Medical  Association. 


ELECTRIC  TREATMENT  OF  THE  STOMACH  139 

stomach  electrode.  From  an  extensive  study  of  the  physi- 
ologic effects  of  direct  electrization  of  the  stomach,  Einhorn 
draws  the  following  conclusions: 

1.  Direct  faradization  of  the  stomach  increases  gastric 
secretion  during  the  application  and  also  for  a  short  time 
afterward. 

2.  Direct  galvanization  of  the  stomach,  with  negative 
pole  within  the  organ,  in  most  instances  diminishes  gastric 
secretion. 

3.  Direct  faradization  as  well  as  galvanization  of  the 
stomach  increases  its  absorbent  faculty. 

His  conclusions  as  to  the  therapeutic  value  of  electricity 
in  the  treatment  of  gastric  diseases  are: 

1.  Du'ect  gastric  electrization  is  a  potent  agent  in  the 
field  of  chronic  (non-malignant)  diseases  of  the  stomach. 

2.  Direct  gastrofaradization  proves  to  be  useful  in  many 
ways  in  the  majority  of  chronic  diseases  of  the  stomach. 

The  favorable  results  appear  very  promptly  in  cases  of 
stomach  dilatation  not  due  to  pyloric  obstruction.  Here  the 
benefit  is  apparent  whether  there  is  subacidity  or  hyper- 
acidity. Cases  of  relaxation  of  the  cardia  (eructation)  and 
of  relaxation  of  the  pylorus  (presence  of  bile  in  the  stomach) 
were  very  favorably  influenced  by  faradization. 

3.  Gastrogalvanization  is  almost  a  sovereign  means  for 
treating  severe  and  very  obstinate  gastralgias,  no  matter 
whether  the  pain  is  of  nervous  origin  or  from  cicatricial 
ulcer. 

4.  Gastrogalvanization  exerts  a  favorable  influence  on 
several  affections  of  the  heart  complicated  with  gastralgia. 

The  good  results  obtained  from  electric  treatment  of 
the  stomach  would  seem  to  indicate  that  the  sensory  and 
secretory  nerves  have  been  stimulated,  although  Freund^ 
made  a  study  of  the  effect  of  electric  current  on  gastric 
secretion  and  found  that  it  was  absolutely  negative,  the 
only  result  being  the  production  of  a  small  amount  of  a 
mucoid   secretion  strongly  alkaline  in  reaction.     He  con- 

1  Virchow's  Archiv,  1905,  Band  clxxx,  Heft  2. 


140  MASSAGE— ELECTRICITY 

eludes  that  food  is  the  only  stimulus  which  will  cause  the 
gastric  glands  to  react. 

Indications. — Electric  treatment  of  the  stomach  is  indi- 
cated in  cases  of  atony  and  ptosis  of  the  stomach  and  its 
sequelae.  Favorable  results  may  be  expected  in  the  ab- 
sence of  organic  stenosis  of  the  pylorus.  Faradization  is 
specially  recommended  in  cases  of  gastric  atony.  A  trial  of 
electricity  is  advisable  as  an  after-treatment  in  cases  in 
which  organic  stenoses  have  been  removed  by  operation. 
A  further  indication  for  electric  treatment  is  furnished 
by  those  neuroses  of  the  stomach  which,  in  the  absence  of 
marked  objective  symptoms,  are  to  be  considered  as  func- 
tional derangements.  As  examples  we  have  paresthesias, 
gastralgias,  pylorospasm,  nervous  vomiting,  buHmia,  and 
anorexia.  In  these  cases  the  galvanic  current  is  employed 
with  good  results,  particularly  in  cases  of  gastralgia,  of 
hysterical  vomiting,  and  the  vomiting  of  pregnancy.  The 
applications  are  made  both  intraventricularly  and  extra- 
ventricularly .  Good  results  have  also  been  secured  with  intra- 
and  extraventricular  faradic  treatment  of  such  conditions. 

As  a  rule,  the  intraventricular  application  of  the  electric 
current  is  more  successful  than  the  extraventricular.  The 
latter  is  especially  adapted  to  those  cases  in  which  the  object 
is  to  exert  an  influence  on  the  abdominal  muscles  as  well 
as  on  the  stomach  itself.  Since  the  normal  gastric  mucous 
membrane  is  not  sensitive,  electric  treatment  of  the  inte- 
rior of  the  stomach  is  easily  accomphshed. 

Intraventricular  Electrization  (Application  of  Electricity  to  the 
Interior  of  the  Stomach). — Several  apparatus  are  at  our 
disposal  for  the  application  of  electricity  to  the  stomach. 
First  of  all  there  is  the  electric  sound  of  Boas  (Fig.  16). 
This  is  a  stomach  tube,  with  numerous  small  perforations 
at  its  lower  extremity,  containing  in  the  interior  a  spiral  of 
platinum  that  is  held  in  place  by  a  clamp  at  the  upper 
opening  of  the  tube.  The  closure  of  the  oral  end  permits 
the  simultaneous  in-and-out  flow  of  water. 

Wegele  makes  use  of  an  ordinary  stomach  tube  with  a  glass 
joint  at  its  oral  end.     By  means  of  a  rubber  tube  a  funnel 


ELECTRIC  TREATMENT  OF  THE  STOMACH 


141 


can  be  joined  to  it,  if  necessary,  and  the  stomach  either  filled 
with  or  evacuated  of  water.  A  thin  metal  wire,  having  a 
button,  is  introduced  into  the  stomach  tube.  The  wire  metal 
is  made  of  such  a  length  that  it  does  not  reach  the  stomach 


Fig.  1G 


Stomach  electrode.      (Boas.) 


Fig.  17 


c 


s 


■€) 


Stomach  electrode.      (Wegele.) 


end  of  the  tube  by  about  1  Cm.— so  that  the  button  will  not 
come  in  direct  contact  with  the  mucous  membrane  of  the 
stomach.  The  exact  length  of  wire  to  be  introduced  into 
the  tube  is  adjusted  by  a  set  screw  (Fig.  17). 

A  third  apparatus  has  been  described  by  Einhorn  (Fig.  18). 
A  metal  button  within  a  perforated  hard  rubber  capsule  is 
joined  by  a  fine  transmission  wire  to  an  electric  battery. 
The  transmission  wire  is  insulated  by  a  thin  rubber  tubing. 


142 


MASS  A  GE—EL^CTRICI  T  Y 


In  using  this  apparatus  the  patient  swallows  the  hard  rubber 
capsule,  which  it  is  sometimes  difficult  to  do. 

Lockwoodi  has  modified  Einhorn's  gastric  electrode  by- 
making  the  following  changes :  The  capsule  is  reduced  in  size 
to  the  dimensions  of  an  ordinary  five-grain  gelatin  capsule. 
To  the  metal  button  within  the  capsule  is  attached  a  spiral 
of  flat  steel,  the  flexibihty  of  which  corresponds  to  that  of 


Fig.  18 


Intragastric  electrode.      (Einhorn.) 

an  ordinary  stomach  tube.  This  spiral  is  covered  by  thin 
rubber  tubing,  and  is  tipped  with  a  binding  pin  for  connec- 
tion with  the  battery. 

Such  an  electrode  can  l)e  easily  introduced  into  the 
stomach  without  discomfort.  The  small  size  of  the  capsule 
allows  of  its  ready  passage,  while  the  spiral  attachment 
is  sufficiently  resistant  to  enable  the  operator  to  push  the 
capsule  along,  just  as  a  .stomach  tube  is  introduced. 

'  Medical  Record,  March  24,  1900. 


ELECTRIC  TREATMENT  OF  THE  STOMACH 


143 


Marshall  has  devised  an  electrode  for  intragastric  electri- 
zation which  the  writer  has  found  very  satisfactory.  It 
consists  of  red  rubber  tubing  twenty  inches  long,  about  the 
thickness  of  a  No.  13  (American  scale)  catheter.  In  one  end 
is  set  a  round  nut  wound  with  a  fine  wire  which  runs  to  the 
other  end  of  the  rubber  tube  and  is  there  fastened  to  a 
slotted  post.  A  screw  with  a  flattened  head  passes  through 
an  oval-shaped  hard  rubber  cap,  and,  being  fastened  into 
the  nut,  holds  the  cap  in  place  so  that  the  latter  protects 
the  stomach  from  direct  contact  with  the  metal.  When  it 
is  desired  to  clean  the  electrode,  unscrew  the  hard  rubber 


Fig.  19 


Combined  stomach  tube  and  electrode.     (Stockton.) 

cap  by  turning  the  screw  to  the  left,  and  press  out  the 
screw,  when  all  parts  can  be  easily  cleaned.  When  the 
screw  is  in  place  it  prevents  any  fluid  entering  the  tube. 
There  is  never  any  trouble  in  introducing  this  electrode, 
and  the  tubing,  being  much  smaller  than  a  stomach  tube, 
causes  very  little  discomfort  to  the  patient. 

Stockton^  describes  an  instrument  which  is  a  combined 
stomach  tube  and  electrode  (Fig.  19).  A  soft  rubber  ordi- 
nary stomach  tube,  28  inches  long,  is  coupled  by  means  of 
a  ground  steel  joint  to  three  feet  of  rubber  tubing,  termi- 
nating in  the  ordinary  funnel.  Through  this  the  stomach  is 
emptied  in  the  usual  way.    Then  the  rubber  tubing  is  dis- 

1  New  York  Medical  Journal,  July  30,  1892. 


144  MASSAGE— ELECTRICITY 

connected  at  the  coupling  without  removing  the  stomach 
tube  itself  from  the  stomach.  There  is  now  introduced 
through  the  stomach  tube,  in  situ,  a  spiral  electrode,  which, 
when  in  place,  completely  closes  the  proximal  opening  of 
the  tube  by  a  ground  steel  plug.  The  distal  extremity  of 
the  spiral  wire  terminates  at  the  upper  of  the  two  fenestrse 
at  the  lower  end  of  the  tube.  This  arrangement  prevents 
the  touching  of  the  mucous  membrane  of  the  stomach  by 
the  metal  point. 

Before  the  introduction  of  the  electric  sound  the  patient 
drinks  a  large  tumblerful  of  lukewarm  water,  or  the  water 
may  be  introduced  by  means  of  the  tube.  The  fluid  dis- 
tributes the  current  to  the  gastric  wall.  For  the  purpose  of 
faradization  a  large  plate  electrode  is  placed  either  on  the 
epigastric  region  or  on  the  back  to  the  left  of  the  seventh 
dorsal  vertebra.  Weak  currents  are  employed  at  first,  the 
current  being  gradually  increased  to  such  a  force  that  the 
patient  is  just  able  to  bear  it.  Rather  forcible  currents 
are  permissible.  The  duration  of  the  seance  is  about  ten 
minutes. 

The  negative  electrode  is  applied  in  the  stomach  for  the 
purpose  of  galvanization.  A  broad  plate  electrode  is  applied 
in  the  same  manner  as  when  faradizing,  the  location  being 
altered  if  necessary;  the  current  is  begun  slowly  and  carried 
up  to  the  strength  of  15  to  20  milliamperes,  and  is  then 
slowly  diminished.  The  duration  of  the  treatment  is  from 
eight  to  ten  minutes. 

Galvanofaradization  is  likewise  applicable.  Intraven- 
tricular faradization  is  especially  recommended  in  atony, 
relaxation  of  the  pylorus,  and  paresis  of  the  cardia  from 
disturbances  in  the  central  nerve  centres  or  from  neuras- 
thenia. Internal  galvanization  is  especially  worthy  of  appli- 
cation in  gastralgias  and  chronic  hypersecretion.  The 
internal  electric  treatment  of  the  stomach  is,  as  Wegele 
specially  remarks,  the  sovereign  method  in  the  treatment 
of  nervous  vomiting. 

Extraventricular  Electrization. — Two  large  rectangular  plate 
electrodes  are  to  be  employed  for  this  purpose.     One  of 


ELECTRIC  TREATMENT  OF  THE  STOMACH  145 

them,  well  moistened,  is  to  be  applied  to  the  region  of  the 
stomach,  the  other  to  the  back.  The  gastric  electrode  is 
put  on  firmly  and  pressed  in  deeply,  making  the  distance 
between  both  plates  as  small  as  possible.  Another  arrange- 
ment of  electrodes  is  as  follows:  Of  two  large  plates,  the 
larger  one  (300  mm.  square)  is  applied  from  the  front  of 
the  abdomen  to  the  spinal  column,  and  the  other  in  a 
similar  way  on  the  opposite  side.  The  distance  between 
the  edges  of  the  two  electrodes  must  be  at  least  one  or 
two  centimeters. 

While  faradizing,  weak  currents  are  used  to  begin  with; 
these  are  gradually  increased,  and  are  finally  made  of  such 
strength  that  the  patient  is  just  able  to  bear  them.  In 
sensitive  persons  the  treatment  may  be  interrupted  by  a 
short  pause  every  half  minute. 

An  electric  roller  cylinder  may  be  employed  instead  of 
the  anterior  electrode;  this  is  rolled  to  and  fro  in  the  region 
of  the  stomach  without  interruption,  and  thus  effects  an 
even  electric  massage  of  the  stomach.  The  electric  brush 
may  likewise  be  used  anteriorly. 

While  galvanizing,  the  current  is  graduaily  increased  to 
15  or  20  milliamperes,  it  being  a  matter  of  indifference 
whether  the  anode  is  situated  in  front  or  behind.  The 
duration  of  the  treatment  is  five  minutes. 

High  frequency  currents  have  been  extensively  used  in 
England  in  the  treatment  of  diseases  of  the  digestive  organs. 
A  million  volts  can  be  made  to  permeate  the  body  by  a 
course  of  autocondensation.  As  a  result,  metabolism  is 
increased  and  muscular  contractions  stimulated,  while 
neural  and  glandular  excitement  is  quieted.  The  effects 
upon  the  intestine  seem  to  be  more  gratifying  than  those 
upon  the  stomach.  This  form  of  electricity  is  employed  in 
gastric  atony  and  gastralgia,  but  more  often  in  intestinal 
neuroses,  membranous  colitis,  and  atonic  and  spastic  con- 
stipation. 

Static  electricity  in  the  treatment  of  diseases  of  the 
stomach  is  disappointing. 

10 


CHAPTER    VII 

H YDROTHERAPEUTICS— M  IN  ERAL  WATERS 
HYDRIATIC   AND   THERMIC   TREATMENT   OF   THE   STOMACH 

Hydrotherapeutics  constitutes  an  important  part  of 
the  treatment  of  diseases  of  the  stomach.  Water  is  essential 
to  the  performance  of  all  the  physiologic  functions.  In 
fact,  it  ranks  first  among  the  therapeutic  resources.  It 
may  be  used  internally  as  a  drink,  as  a  spray,  in  lavage, 
or  as  a  douche,  and  externally  in  baths,  packs,  moist  rub- 
bing, and  slapping. 

In  the  use  of  water  as  a  therapeutic  agent  the  physician 
should  have  clearly  in  mind  the  results  to  be  attained.  Cold 
wacer  applied  externally  should  have  a  stimulating  effect,  as 
shown  by  the  skin  reaction.  In  disease  conditions  of  the 
stomach  the  stimulus  should  be  moderate  in  character. 
Weak  stimuli  tend  to  increase  vitality,  while  stronger  ones 
have  an  inhibitory  effect.  The  physician  should  exercise 
great  precaution  in  the  treatment  of  gastric  cases  compli- 
cated with  anemia,  nervousness,  and  debility.  In  moist 
rubbing  and  slapping  the  water  should  be  below  bod}^  tem- 
perature, care  being  exercised  to  avoid  undue  shock  to 
sensitive  patients.  The  temperature  of  the  water  should 
vary  from  85°  to  60°  F.  The  wet  rub  is  best  given 
early  in  the  morning,  inasmuch  as  the  skin  reacts  best  at 
this  time,  owing  to  the  fact  that  it  is  uniformly  heated  on 
rising.  The  patient  should  stand  barefooted  on  some  non- 
conducting substance,  such  as  a  piece  of  carpet  or  a  cork 
mat.  A  large  linen  sheet  wrung  out  of  water  at  the  proper 
temperature  is  placed  about  him  by  the  physician  or  at- 
tendant, who  then  proceeds  to  rub  vigorously  his  back, 
arms,  and  legs.  The  patient,  meanwhile,  assists  by  rul)bing 
the  chest  and  abdomen.    In  a  few  moments  this  should  be 


IIYDRJATIC  AND  THERMIC  TREATMENT  147 

followed  b}^  an  agreeable  feeling  of  warmth.  The  patient 
should  be  wiped  thoroughly,  and  should  either  rest  for  half 
an  hour  or  take  a  short  walk  before  breakfast. 

The  ''rub-off,"  according  to  Strasse,  is  made  as  follows: 
The  patient  elevates  his  arms,  and  is  wrapped  quickly  into 
a  moist  linen  sheet — one  corner  of  which  is  clamped  by  one 
lowered  arm  while  the  sheet  is  wound  around  to  overlap  it, 
and  is  clamped  under  the  other  arm  also.  The  towel  is  then 
wrapped  around  the  patient's  trunk  so  that  the  shoulders  are 
covered.  Energetic  rubbing  and  beating  are  performed  by  the 
attendant  with  the  palm  of  the  hand.  As  soon  as  the  patient 
experiences  a  feeling  of  warmth  he  is  released  from  the  pack 
and  rubbed  dry.  In  the  absence  of  an  attendant  the  patient 
may  dry  himself  by  rubbing  vigorously  with  a  rough  towel. 

Should  the  skin  reaction  following  the  use  of  the  wet 
pack  not  be  well  marked,  before  another  treatment  the 
temperature  of  the  patient  should  be  raised  either  by  moder- 
ate exercise  or  by  a  dry  rub.  If,  after  this  procedure,  the 
cold  rub  fails  to  bring  about  a  skin  reaction,  it  should  be 
omitted;  better  sponge  the  patient  off  with  water  at  a  tem- 
perature agreeable  to  his  sensitiveness — three  parts  water 
to  one  of  vinegar,  or  one  part  alcohol  to  two  of  water,  may 
be  used.  The  bath  may  be  given  by  applying  the  mixture 
to  the  whole  body  before  attempting  to  dry,  or  a  portion  of 
the  body,  an  arm  or  a  leg,  may  be  bathed  and  then  dried 
until  the  w^hole  body  has  participated  in  the  operation. 

Half  Baths. — What  are  known  as  half  baths  have  a  favor- 
able and  stimulating  effect  upon  the  nervous  system.  The 
patient  sits  in  a  bathtub  in  which  the  water  at  90°  F.  reaches 
as  high  as  his  umbilicus.  In  treating  more  robust  patients 
the  temperature  of  the  water  may  be  as  low  as  82°  or  77°  F. 
The  patient  should  immerse  himself  to  the  neck  in  the  water 
and  return  to  the  sitting  posture.  The  attendant,  assisted 
by  the  patient,  proceeds  to  rub  the  latter  vigorously.  The 
w^hole  bathing  process  should  last  about  three  or  four 
minutes,  during  which  time  the  patient  should  be  active. 
On  stepping  out  of  the  tub  he  is  covered  by  a  dry  sheet 
and  rubbed  dry  while  either  sitting  on  a  chair  or  lying  in 


148  HYDROTHERAPEUTICS— MINERAL  WATERS 

bed.  The  bath  may  be  followed  b}'  moderate  exercise  or 
by  rest  in  the  recumbent  posture  in  bed.  The  patient  should 
experience  a  feeling  of  comfort  after  such  treatment. 

The  half  bath,  so  called,  may  be  varied  in  several  ways. 
The  patient  may  sit  for  five  to  ten  minutes  immersed  to  the 
neck  in  water  at  a  temperature  of  84°  to  90°  F.  Then  the 
water  is  allowed  to  flow  out  of  the  tub  until  it  is  at  the  level 
of  the  patient's  umbilicus,  when  the  attendant  begins  to  rub 
him  and  sprinkle  him  mth  water.  The  half  bath  may  be 
made  even  more  intense  and  stimulating  by  allowing  cold 
water  to  flow  into  the  tub  during  the  manipulations  of 
the  attendant.  In  all  these  procedures  the  head  should  not 
be  allowed  to  become  wet. 

Cold  Entire  Pack. — What  is  known  as  the  cold  entire  pack 
produces  a  stimulating  and  refreshing  effect  when  it  is  em- 
ployed under  proper  conditions.  A  large  flannel  blanket  is 
spread  upon  the  bed  or  couch,  and  over  it  a  sheet  which 
has  been  dipped  into  water  of  about  60°  to  50°  F.,  and 
which  remains  fairly  saturated  with  it.  After  the  morning 
evacuation  of  the  bow^els  and  bladder  the  patient  is  packed 
into  the  sheet  and  blanket  so  that  his  shoulders  and  arms 
are  included  in  the  folds.  A  stimulating  effect  is  produced 
by  removing  the  pack  as  soon  as  the  reaction  sets  in.  To 
prolong  the  duration  of  the  pack  beyond  this  point  produces 
a  quieting  effect  upon  the  patient,  so  that  sometimes  he 
becomes  drowsy  and  has  a  desire  to  sleep. 

Should  the  desired  reaction  not  take  place  after  the  cold 
or  wet  rub,  this  operation  may  be  preceded  by  the  cold  pack 
until  the  body  becomes  sufficiently  warmed. 

In  this  mode  of  hydrotherapeutic  treatment  of  patients 
with  gastric  disease  we  note  at  first  a  slowing  of  the  tem- 
poral pulse,  which  soon  returns  to  the  normal  rate. 

To  avoid  hyperemia  in  the  head  or  in  the  region  of  the 
heart,  cold  compresses  may  be  applied  to  the  head,  or  the 
cooling  apparatus  of  Leiter  may  be  applied  over  the  region 
of  the  heart. 

Warm  Entire  Pack. — By  employing  lukewarm  water  in  our 
hydrotherapeutic  treatment  we  may  obtain  a  sedative  efi"ect. 


HYDRIATIC  AND  THERMIC  TREATMENT  149 

The  blood  pressure  diminishes,  and  with  the  dilatation  of 
the  bloodvessels  the  painful  symptoms  are  alleviated.  The 
patient  becomes  quiet,  and  sleep  ensues. 

In  the  prolonged  warm  entire  pack  the  patient  is  packed 
in  cloths  which  have  been  dipped  into  water  of  from  95°  to 
100°  F.  Since  the  cloths  cool  off  rapidly,  this  pack  must  be 
administered  quickly. 

Prolonged  Baths. — The  prolonged  lukewarm  full  bath  acts 
as  an  agreeable  sedative  and  hypnotic.  The  temperature 
of  the  water  should  be  in  the  neighborhood  of  95°  F. 
The  patient  should  be  placed  in  a  comfortable  position, 
preferably  recHning.  The  water  should  reach  over  the 
shoulders.  The  duration  of  the  bath  should  be  from  five 
to  twenty-five  minutes.  Should  the  bath  be  more  pro- 
tracted, care  must  be  taken  that  the  water  does  not  cool 
off  too  much.  Any  kind  of  exertion  is  to  be  avoided,  both 
before  and  after  the  bath.  When  the  end  desired  is  the 
induction  of  sleep,  the  tepid  bath  is  best  employed  toward 
evening  or  immediately  before  retiring. 

The  prolonged  baths  may  be  medicated  by  the  addition 
of  various  chemical  agents.  Sodium  chloride  may  be  used 
with  the  water  so  as  to  make  a  1-per-cent.  or  a  2-per-cent. 
solution.  Carbon  dioxide  at  times  exerts  a  beneficial  in- 
fluence upon  nervous  patients.  The  carbon  dioxide  bath 
may  be  prepared  in  private  homes  by  the  combination 
of  sodium  bicarbonate  with  mineral  acids  or  with  acetic 
acid.  Oxygen  baths  are  beneficial  in  the  treatment  of 
nervous  dyspepsia.  Such  baths  are  prepared  by  adding 
soda  perborate  and  a  manganese  salt  to  the  water,  the 
soda  perborate  being  broken  up  by  the  manganese  salt  in 
the  presence  of  water,  with  the  liberation  of  oxygen.  The 
immersion  of  the  body  in  such  an  effervescing  solution  gives 
a  powerful  impetus  to  the  nervous  system.  Many  patients 
find  the  addition  of  250  to  500  grammes  of  pine-needle 
extract  to  the  bath  very  agreeable,  but  the  good  effect  is 
probably  largely  mental. 

Indications. — The  indications  for  hydrotherapeutic  treat- 
ment in  gastric  disease  are  not  always  clear.     In  a  general 


150  HYDROTHERAPEUTICS— MINERAL  WATERS 

way,  hot  applications  tend  to  the  diminution  of  pain  and 
have  an  antispasmodic  effect;  cold  applications,  on  the  other 
hand,  stimulate. 

Compresses. — Hot  compresses  in  the  form  of  poultices  are 
well  known  to  the  laity.  To  prepare  a  mashed-potato 
poultice,  which  is  one  of  the  best  forms  of  cataplasm,  freshly 
cooked  potatoes  are  placed  upon  a  piece  of  cheesecloth,  a 
portion  of  which  is  folded  in  the  form  of  a  sac.  This  bag 
may  be  closed  by  means  of  safety  pins  or  a  few  stitches. 
The  potatoes  are  crushed  with  a  wooden  roller,  after  which 
the  poultice  is  ready  for  use.  This  poultice  is  not  only  the 
cleanest,  but  retains  its  warmth  longer  than  any  other. 

Linseed  poultices  are  made  by  boiling  the  linseed  meal 
to  a  thick  consistency.  The  mass  is  then  placed  into  the 
cloth  and  used  in  the  same  manner  as  the  potato  poultice. 
The  linseed  poultice  is  not  so  satisfactory,  owing  to  the 
fact  that  it  adheres  to  the  parts  and  is  apt  to  undergo 
acid  fermentation. 

It  is  hardly  necessary  to  say  that  cataplasms  should 
always  be  applied  hot  and  of  sufficient  size  to  cover  the 
upper  portion  of  the  abdomen.  To  secure  the  desired 
effect,  two  poultices  should  be  prepared,  so  that  one  may 
be  in  the  steam  bath  while  the  other  is  doing  duty  on  the 
patient.  To  maintain  the  heat,  double  boilers  are  very  con- 
venient. The  cataplasm  is  placed  in  a  tray  with  a  perforated 
bottom  held  above  the  water  level  in  the  boiler.  The  water 
may  be  heated  by  a  spirit  lamp  or  other  means,  so  that  the 
poultice  when  not  in  use  is  subjected  to  the  action  of  steam. 
The  apparatus  should  be  kept  covered. 

Heat  may  be  applied  to  the  abdominal  or  gastric  region 
by  means  of  hot  towels,  or  heated  i)latos  well  wrajipcMl  in 
cloth.  The  flat  stomach  bottle  of  aluminum,  rubber,  or  zinc 
is  of  practical  value.  Flat  rubber  bottles  or  boxes  filled  with 
some  chemical  substance  are  obtainable,  which,  after  being 
subjected  to  the  action  of  boiling  water  for  fifteen  minutes 
will  retain  their  heat  for  several  hours,  r^loctric  warming 
pads  and  electrothermic  bottles  are  of  inoi-e  i-eceni  in\(>n- 
tion.      Leiter's  tubes  are  made  of  (in,  nlinninuin,  or  hard 


MYDRIATIC  AND  THERMIC  TREATMENT  151 

rubber;  they  are  placed  upon  the  upper  half  of  the  abdomen 
of  the  patient,  and  hot  water  is  allowed  to  run  through 
the  coil.  The  electrothermic  bottle,  electric  warming 
pad,  or  Leiter's  coils  may  be  converted  into  moist  hot 
compresses  by  encasing  them  in  moistened  folds  of 
cloth.  The  temperature  of  the  hot  cataplasm  must  be 
modified  according  to  the  requirements  of  the  patient's 
comfort. 

When  hot  cataplasms  are  used  for  a  long  period  of  time, 
for  instance  in  gastric  ulcer,  the  skin  over  the  hypogastric 
region  should  be  thoroughly  cleansed  with  soap  and  water 
and  weak  bichloride  solution,  and  a  piece  of  flannel  or  linen 
laid  over  the  parts  and  made  secure  by  adhesive  plaster. 
This  forms  a  basis  for  the  hot  compress.  In  this  way  blisters 
from  heat  may  be  avoided. 

The  Priessnitz  bandage  is  applied  moist,  and  either  hot 
or  cold,  so  that  it  produces  a  hyperemic  condition  of  the 
skin.  The  application  of  this  bandage  is  accompanied  by 
an  agreeable  feeling  of  warmth.  The  effect  is  sedative, 
analgesic,  and  frequently  hypnotic.  The  Priessnitz  bandage 
consists  of  a  towel  folded  several  times,  dipped  in  warm 
water,  and  wrung  out.  This  is  placed  over  the  stomach 
and  covered  by  oiled  silk  or  gutta-percha,  with  a  flannel 
binder  to  retain  it  in  place.  This  bandage,  which  should  be 
sufficiently  tight  not  to  slip  down,  is  adjusted  at  night  and 
allowed  to  remain  on  the  patient  until  morning.  Alcohol, 
50  per  cent.,  has  a  more  stimulating  effect  than  water. 

Winternitz  reconunends  the  use  of  coiled  tubing,  such 
as  the  Leiter  cooling  apparatus,  in  which  water  of  a  tem- 
perature of  130°  to  55°  F.  is  allowed  to  circulate.  The 
coils  are  interposed  between  the  moist  linen  and  woolen 
bandages  (Fig.  20).  Winternitz  recommends  this  mode  of 
treatment  in  nervous  gastric  diseases  and  in  functional 
motor  disturbances  of  the  stomach. 

Douches. — Douches  are  often  applied  externally  with  good 
effect.  We  have  the  fan  douche  and  the  so-called  Scotch 
or  interrupted  douche.  A  somewhat  cumbersome  apparatus 
is  required  for  the  administration  of  the  latter.    With  this 


152 


HYDROTHERAPEUTICS— MINERAL  WA  TERS 


apparatus  the  temperature  may  be  quickly  alternated  from 
100°  to  50°  F.  and  an  interrupted  jet  of  water  thrown  over 
the  region  of  the  stomach.     We  obtain  by  the  use  of  this 


Fig.  20 


Coiled  tubing.      (Winternitz.) 


apparatus  not  only  alternate  contraction  and  dilatation 
of  the  capillaries  of  the  skin,  but  reflex  contractions  of  the 
abdominal  muscles  as  well.  A  stimulus  is  likewise  given 
to  the  peristaltic  movements  of  the  intestine. 


MINERAL  WATERS  153 


MINERAL  WATERS 

An  extensive  therapy  for  diseases  of  the  stomach  and 
intestine  is  provided  by  the  so-called  mineral-water  cures, 
bath  cures,  climate  cures,  and  sea  baths.  Mineral  waters  are 
solutions  of  varying  strengths  of  salts  and  gases  in  water. 
The  salts  present  are  usually  very  small  in  proportion  to 
the  amount  of  water.  In  spite  of  the  fact  that  these  waters 
are  among  our  oldest  therapeutic  agents,  we  have  much 
to  learn  in  regard  to  their  physiologic  action.  We  have  as 
yet  no  well-defined  scientific  basis  of  procedure  in  regard  to 
their  use.  Such  investigators  as  von  Noorden,  Dopper, 
Lareche,  Jaworski,  Boas,  and  Wolf  have  sought  to  point  out 
the  direct  local  and  systemic  effects,  but  their  results  have 
been  contradictory.  In  the  absence  of  scientific  data  we 
must  continue  to  base  our  use  of  mineral  waters  on  empirical 
knowledge,  controlled  only  by  what  we  know  of  their  indi- 
vidual constituents. 

The  gaseous  constituents  are,  chiefly,  carbon  dioxide  and 
sulphuretted  hydrogen.  The  solid  constituents  are  salts  of 
sodium,  potassium,  magnesium,  aluminum,  calcium,  iron, 
iodine,  bromine,  chlorine,  and  sulphur.  Some  of  these 
waters  have  a  purgative  effect,  some  laxative,  and  some 
diuretic. 

Classification. — 1.  Alkaline  chlorine  waters. 

2.  Sodium  chloride  waters. 

3.  Alkaline  carbonated  waters. 

4.  Ferruginous  or  chalybeate  waters. 

5.  Bitter  waters. 

Alkaline  Chlorine  Waters. — Waters  from  the  alkaline  chlorine 
springs  contain  principally  sodium  chloride,  sodium  sulphate, 
bicarbonate  of  soda,  and  carbon  dioxide.  In  the  United 
States  we  have  Arondack,  at  Saratoga,  N.  Y. ;  Bedford,  at 
Bedford,  Pa.;  Berry  Hill,  Elkwood,  Va.;  Crab  Orchard,  Ken- 
tucky; French  Lick,  Indiana;  Gate  Springs,  Tennessee;  West 
Baden,  Indiana;  Hot  Sulphur  Springs,  Colorado;  Gibson's 
Mineral  Wells,  Texas;  and  Ferris  Hot  Springs,  Montana. 


154  HYDROTHERAPEUTICS— MINERAL   WATERS 

To   this   class   belong   the   springs   of   Carlsbad,   Bertrich, 
Marienbad,  Rohitsch,  Tarasp,  and  Franzensbad,  in  Europe. 

Carlsbad  and  Bertrich  are  warm  springs.  Carlsbad  is 
especially  famous  in  regard  to  the  treatment  of  diseases  of 
the  stomach.  It  has  been  found  that  a  single  dose  or  a  few 
small  doses  of  Carlsbad  water  or  salt  will  excite  a  copious 
secretion  of  acid,  but  that  larger  doses  continued  for  a 
longer  period  of  time  may  greatly  diminish  the  secretion 
of  gastric  juice.  Carlsbad  water  dissolves  mucus,  increases 
the  peristaltic  action  of  the  stomach,  and,  owing  to  its 
warmth,  diminishes  gastric  sensitiveness. 

According  to  Riegel,  a  course  of  Carlsbad  water  is  advis- 
able as  after-treatment  in  cases  of  ulcer  of  the  stomach 
without  atony,  especially  cases  in  which  hyperacidity  is 
present.  The  treatment  at  Carlsbad  is  likewise  indicated 
in  chronic  acid  gastritis,  especially  when  there  is  a  copious 
secretion  of  mucus,  and  in  hyperacidity  not  of  nervous 
origin.  Carlsbad  treatment  may  be  tentatively  tried  in 
cases  of  dyspepsia  with  hyperacidity,  or  in  those  in  which 
the  peptic  powers  are  but  slightly  diminished,  also  in  cases 
of  mild  atony  accompanied  by  constipation.  The  Carlsbad 
cure  is  contraindicated  in  cases  of  cancer,  marked  dilatation, 
atony,  stomach  diseases  with  greatly  decreased  secretion, 
nervous  dyspepsia,  and,  according  to  Boas,  also  in  genuine 
forms  of  confirmed  chronic  gastritis  with  diminution  or 
absence  of  hydrochloric  acid. 

The  individual  Carlsbad  springs  vary  in  temperature. 
The  springs  with  moderate  temperatures  are  preferable  to 
those  with  higher  degrees  of  heat,  especially  for  the  treat- 
ment of  ulcer  of  the  stomach.  Boas  recommends  and  re- 
ports good  results  from  the  employment  of  small  doses  of 
the  very  hot  springs  in  catarrhal  affections  of  the  small  and 
large  intestine. 

The  good  results  following  the  use  of  the  Carlsbad  waters 
are  partly  due  to  the  excellent  diet  prescribed  at  Carlsbad 
resorts. 

The  waters  of  Bertrich,  which  are  weaker  than  those  of 
Carlsbad,  are  employed  in  a  similar  manner.     The  water 


MINERAL  WATERS  155 

of  Marienbad,  which  contains  twice  the  quantity  of  sodium 
sulphate,  more  sodium  chloride  and  more  free  carbon  dioxide 
than  that  of  Carlsbad,  has  a  stimulating  effect  upon  motility 
and  secretion.  The  other  waters  mentioned  act  in  a  similar 
manner.  Many  of  these  contain  rather  large  quantities  of 
free  carbon  dioxide,  which  promotes  the  secretion  of  hydro- 
chloric acid.  It  is  therefore  advisable  to  employ  these  waters 
in  atony,  and  in  subacid  and  anacid  conditions.  Boas  recom- 
mends Elster  and  Marienbad  in  cases  where  Carlsbad  would 
otherwise  be  indicated,  but  which  are  complicated  with 
habitual  constipation.  He  advises  Tarasp  for  cases  in 
which  it  is  desirable  to  treat  nervous  conditions  as  well  as 
the  stomach. 

Sodium  Chloride  Waters. — In  the  United  States  are  the  Springs 
at  Ballston,  N.  Y.;  Hathorn,  Congress,  Kissingen,  Selters, 
and  Champion,  at  Saratoga,  New  York ;  Colorado  Springs, 
Colorado;  Wasatko  Springs,  Utah;  and  in  Canada  the 
springs  at  St.  Catharines,  Ontario.  In  Europe  are  the 
springs  of  Kissingen,  Homburg,  Soden,  Wiesbaden,  Pyr- 
mont,  and  Mergentheim. 

Sodium  chloride  taken  after  a  meal  has  the  effect  of 
inhibiting  hydrochloric  acid  secretion  and  peptic  digestion 
without  interfering  in  any  way  with  the  motility  of  the 
stomach.  Experiments  with  sodium  chloride  waters,  espe- 
cially Kissingen  and  Homburg,  on  patients  with  gastric 
disease,  have  shown,  on  the  contrary,  that  in  cases  of  gas- 
tritis with  subacidity  the  acid  secretion  was  increased ;  while 
in  hyperacidity  the  employment  of  sodium  chloride  waters 
is  frequently  followed  by  a  marked  decrease  in  the  hydro- 
chloric acid  secretion.  Their  effects  in  subacid  conditions 
seem  to  be  fairly  constant,  that  is,  stimulating  the  secretion 
of  free  hydrochloric  acid;  but  observers  are  at  variance 
regarding  their  effects  in  hyperacidity.  In  subacidity  with 
profuse  mucous  secretion  the  sodium  chloride  waters  cause 
a  marked  diminution  in  the  amount  of  mucus. 

In  cases  of  subacid  gastritis,  especially  in  their  incipiency, 
the  secretion  of  hydrochloric  acid  may  be  restored  to  normal 


156  H YDRO THERA PE UTICS—MINERA L  WA  TERS 

by  a  course  of  treatment  with  the  sodium  chloride  waters. 
To  obtain  the  favorable  effect  on  the  gastric  secretion 
the  waters  (Saratoga,  Kissingen,  Wiesbaden)  should  be 
taken  on  an  empty  stomach,  and  the  patient  should  refrain 
from  partaking  of  food  until  they  have  passed  out  of  the 
stomach. 

Riegel  would  not  use  sodium  chloride  waters  in  the  treat- 
ment of  hypersecretion.  Boas  is  strongly  opposed  to  their 
use  in  atony  and  dilatation;  he  favors  a  trial  of  them, 
however,  in  cases  of  ulcus  ventriculi  where  the  ulcer  has 
become  healed  or  cicatrized. 

Alkaline  Carbonated  Waters. — The  alkaline  carbonated  waters 
contain  as  their  chief  constituents  bicarbonate  of  soda 
and  carbon  dioxide.  The  principal  waters  of  this  class  in 
the  United  States  are  Allouez,  Green  Bay,  Wis.;  Peerless, 
Saratoga,  N.  Y.;  Vichy,  at  Saratoga;  Skaggs,  Hot  Springs, 
Cal.;  Canon  City,  Colorado.  In  Europe  are  Bihn,  Fach- 
ingen,  Neuenahr,  Giesshiibel,  Geilnou,  Preblau,  Salzbrunn, 
and  Mchy.  Owing  to  the  fact  that  these  waters  contain 
sodium  carbonate,  they  are  indicated  particularly  in  the 
treatment  of  hyperacidity,  hypersecretion,  and  eructations. 
After  a  course  of  treatment  with  the  alkaline  carbonated 
waters,  particularly  Vichy,  an  increase  in  the  motility  of  the 
stomach  has  been  noted.  It  is  important  that  these  waters 
be  administered  warm,  to  lessen  the  sensitiveness  of  the 
stomach. 

The  alkaline  saline  waters  contain,  in  addition  to  carbon 
dioxide  and  bicarbonate  of  soda,  small  quantities  of  sodium 
chloride.  In  the  United  States  are  Deep  Rock  Springs, 
Oswego,  N.  Y.;  Manitou,  Manitou,  Col.;  and  Sheboygan, 
Sheboygan,  Wis.  They  increase  the  secretion  of  gastric 
juice,  and  are  indicated  in  chronic  gastritis,  slight  atony, 
and  secondary  catarrhs. 

Ferruginous  Waters. — These  waters  contain  bicarbonate  of 
iron  and  sulphate  of  iron.  The  ferruginous  springs  of  the 
United  States  are  Mardela,  Maryland;  Rock  Enon,  \'irginia; 
Church  Alum,  Virginia;  Owosso,  Michigan;  Sparta  Mineral 
Wells,    Wisconsin;     Fruitport    Wells,    Michigan;    Wilbot, 


MINERAL  WATERS  157 

Oregon;  Mono  Lake,  California;  Bath  and  Bedford  Alum, 
Virginia.  In  Europe  there  are  the  acid  iron  springs  of  Elster 
and  Franzensbad,  and  the  waters  of  Reinerz,  Rippoldsau, 
Schwalbach,  and  Bartfeld.  These  waters  are  useful  in  the 
treatment  of  chronic  dyspepsia  and  gastric  pains  occurring 
in  anemia  and  chlorosis. 

Bitter  Waters. — Bitter  waters  are  indicated  in  the  treatment 
of  diseases  of  the  stomach  secondary  to  intestinal  indigestion 
when  constipation  is  present.  They  inhibit  the  secretion 
of  gastric  juice.  Their  use  is  contraindicated  in  gastric 
ulcer.  Among  the  bitter  waters  we  have  Abilena,  Franz 
Josef,  Pluto  (concentrated),  Veronica,  Arondack,  Saratoga, 
and  West  Baden  Sprudel. 

All  mineral  waters  should,  by  preference,  be  taken  at 
the  springs  themselves;  it  is  a  matter  of  experience  that 
the  waters  affect  the  patients  more  favorably  when  this 
is  done.  At  these  resorts  the  patient  is  free  from  excite- 
ment and  business  cares;  his  surroundings,  the  atmosphere, 
and  scenery  are  conducive  to  peace  of  mind,  and  dietary 
regulations  are  more  apt  to  be  faithfully  carried  out.  These 
waters,  however,  may  be  taken  at  home  if  a  sojourn  at 
the  springs  is  impossible. 

Basch^  sums  up  the  contraindications  in  the  use  of  the 
various  mineral  waters: 

1.  Gastric  motor  insufficiency  of  any  grade  and  from 
any  cause  whatever.  It  is  well  known  that  no  appreciable 
amount  of  water  is  absorbed  from  the  stomach,  and  that 
sahne  solutions  cause  a  transudation  into  the  lumina  of 
hollow  viscera;  hence  the  insufficiency  can  only  be  aggra- 
vated. In  these  conditions  there  is  the  further  danger 
of  increased  distention  from  the  large  amount  of  free  car- 
bonic acid  gas  usually  present  in  the  waters.  In  all  non- 
acute  conditions  of  this  kind  gastric  lavage  with  a  mineral 
water  properly  adapted  to  the  chemistry  of  the  stomach 
has  been  found  to  be  very  useful. 

2.  The  existence  or  the  probability  of  a  malignant  growth. 

3.  Acute  hemorrhagic  conditions. 

1  New  York  Medical  Journal,  March  6,  1909. 


158  HYDROTHERAPEUTICS— MINERAL  WATERS 

4.  Gastro-intestinal  tuberculosis. 

5.  Intestinal  obstruction.  A  possible  exception  in  this 
category  may  be  found  in  obstructions  due  to  impact-ed 
feces. 

6.  In  acute  gastritis  mineral  waters  are  apt  to  do  more 
harm  than  good. 

As  a  fundamental  principle  no  systematic  mineral  water 
treatment  in  gastro-intestinal  disease  should  be  recommended 
until  a  diagnosis,  or  at  least  careful  examinations,  including 
a  thorough  chemical  analysis  of  the  stomach  contents,  and 
in  many  cases  the  feces,  too,  shall  have  been  made. 

Mineral  Baths,  Sea  Baths,  Climatic  Cures. — Mineral-water 
treatment  is  sometimes  combined  with  bath  cures  so  called. 
Salt  and  mud  baths  have  been  found  efficacious  in  the 
treatment  of  gastric  affections.  Waters  containing  enough 
sodium  chloride  to  raise  their  specific  gravity  are  designated 
salt.  Baths  in  such  waters  are  of  three  kinds — weak  (1  to 
2  per  cent,  salt),  medium  (up  to  6  per  cent.),  and  strong 
(above  6  per  cent.).  Three  per  cent,  mineral  salt  solutions 
are  employed  for  bathing  purposes.  Sea  baths  have  a 
favorable  effect  in  inflammatory  and  exudative  processes 
of  the  stomach  and  intestinal  tract,  as  well  as  in  cases  of 
chronic  peritonitis.  Alud  baths  are  best  applied  at  Elster, 
Franzensbad,  or  Mudlavia,  Indiana ;  they  are  very  retentive 
of  heat,  conserving  and  prolonging  the  caloric  effect  upon 
the  skin.  Upon  this  fact  depends  their  value  in  irritable 
conditions  of  the  stomach,  pylorospasm,  gastric  ulcer,  and 
gastric  neuroses.  Sea  baths  are  indicated  for  patients  with 
dyspepsias  due  to  neurasthenic  conditions,  gastric  atony,  or 
ptosis.  Cold  sea  baths  have  a  tonic  effect,  due  largely  to 
the  salt  they  contain  and  to  the  movements  of  tlio  waves. 
They  stimulate  gastric  digestion.  Well-nourished  j^atients 
suffering  from  neuroses,  as  well  as  the  anemic,  do  well  at 
the  seaside. 

Change  of  climate  and  residence  in  high  altitudes  are 
most  suitable  to  gastric  patients  who  are  likewise  suffering 
from  mental  overwork  and  nervousness. 

The  institutions  to  be  preferred  are  the  smaller  sanitaria 


MINERAL   WATERS  159 

in  which  diseases  of  the  stomach  and  intestine  are  treated 
exclusively  and  along  strictly  scientific  lines. 

American  Mineral  Waters.— Bulletin  91  of  the  Bureau  of 
Chemistry,  United  States  Department  of  Agriculture,'  con- 
tains a  report  on  American  commercial  mineral  waters. 
Herewith  are  given  the  results  of  the  Bureau's  analysis 
of  the  most  prominent  and  best-known  waters: 

Crockett  Arsenic-lithia  Water,  Shawsville,  Virginia 
One  U.  S.  gallon  contains: 

Solids.  Grains. 

Ammonium  chloride trace 

Potassimn  chloride 0.60 

Lithium  chloride trace 

Magnesium  bicarbonate 1.74 

Calcium  bicarbonate 13 .  46 

Sodium  metaborate small  amount 

Potassium  sulphate 0.17 

Sodium  sulphate 3 .  09 

Magnesium  sulphate 4.59 

Disodium  arsenate 0.19 

Calcium  sihcate 0.52 

Ferric  oxide  and  alumina 0.06 

Potassium  iodide trace 

Sodium  nitrate 0.02 

Sodium  nitrite heavy  trace 

Silica '    2.53 

Total 26.97 

Great  Bear  Water,  Fulton,  New  York 

One  U.  S.  gallon  contains: 

Solids.  Grains. 

Magnesium  chloride 0.73 

Lithium  chloride trace 

Potassium  chloride 0.18 

Sodium  chloride 1.01 

Ammonium  chloride trace 

Magnesium  sulphate 0 .  89 

Sodium  nitrate 0 .  70 

Sodium  nitrite • trace 

Magnesium  bicarbonate 1.61 

Calcium  bicarbonate 7.25 

Ferrous  bicarbonate 0.06 

Silica 0.56 

Total 12.99 

1  Journal  of  the  American  Medical  Association,  ^larch  14,  1908. 


160  HYDROTHERAPEUTICS— MINERAL  WATERS 


Deep  Rock  Water,  Os'svego,  Xew  York 

One  U.  S.  gallon  contains: 

Solids.  Grains. 

Ammonium  chloride 0.01 

Lithium  chloride trace 

Potassium  chloride 0.40 

Sodium  chloride 112.98 

Sodiimi  sulphate 3 .  32 

Calcimn  phosphate trace 

Calcium  bicarbonate 3 .  08 

Magnesimn  bicarbonate 1.21 

Sodium  bicarbonate 12 .  58 

Sodium  nitrate 0.70 

Sodium  nitrite trace 

Ferric  oxide  and  alumina 0.02 

Silica 0.61 

Total 135.00 


Tate  Epsom  W.a.ter,  Tate  Springs,  Texxes.see 

One  U.  S.  gallon  contains: 

Solids.  Grains. 

Ammonimn  chloride trace 

Sodimn  chloride 0.12 

Lithium  chloride 0.03 

Pota.ssiimi  chloride 0.91 

Sodium  sulphate 4.38 

Magnesium  .sulphate 34.71 

Calciimi  sulphate 76.53 

Sodiima  nitrate 0.02 

Calcium  bicarbonate 20 .  05 

Calcium  silicate 0.24 

Ferric  oxide  and  alumina 0.23 

Silica 1.13 


Total 138.35 


MINERAL   WATERS  161 


Geneva  Lithia  Water,  Geneva.  New  York 
One  U.  S.  gallon  contains: 

Solids.  Grains. 

Ammonium  chloride trace 

Sodium  chloride 19.16 

Potassium  chloride 0.44 

Lithium  chloride 0.03 

Potassium  iodide trace 

Sodium  sulphate 0.16 

Magnesium  sulphate 33.36 

Calcium  sulphate 87.01 

Calcium  bicarbonate 18.89 

Sodium  metaborate trace 

Sodium  nitrate trace 

Sodium  nitrite trace 

Ferric  oxide  and  alumina 0.05 

SiHca 0.82 

Calcium  phosphate trace 

Total 159.82 


Manitou  Water,  Manttou,  Colorado 
One  U.  S.  gallon  contains: 

Solids.  Grains. 

Sodium  chloride 17.58 

Ammonium  chloride trace 

Potassium  chloride 7.89 

Lithium  chloride          0.08 

Sodiima  bicarbonate 69.20 

Magnesium  bicarbonate 27.65 

Calcium  bicarbonate 107 .  56 

Ferrous  bicarbonate 0 .  33 

Potassium  bromide faint  trace 

Sodium  sulphate 18.80 

Sodium  metaborate small  amoxmt 

Mangano-manganic  oxide 0.14 

Silica 2.54 

Total 251.77 


11 


162  HYDROTHERAPEUTICS— MINERAL  WATERS 


Allotjez  Mineral  Water,  Green  Bay,  Wisconsin 

One  U.  S.  gallon  contains: 

Solids.  Grains. 

Ammonium  chloride trace 

Lithium  chloride trace 

Sodium  chloride 1.60 

Magnesium  chloride 0.99 

Potassium  chloride 0.17 

Magnesium  sulphate 4.27 

Calcium  phosphate trace 

Sodium  nitrate 2.11 

Magnesimn  bicarbonate 8.41 

Calcium  bicarbonate 18.43 

Ferric  oxide  and  alumina 0.07 

Calcium  silicate 1.50 

Silica 0.45 

Total 38.00 


Blue  Lick  Water,  Blue  Lick^Springs,  Kentucky 
One  U.  S.  gallon  contains: 

Solids.  Grains. 

Ammonium  chloride 0.13 

Potassium  chloride 7.72 

Magnesium  chloride 40.55 

Sodimn  chloride 400.43 

Calcium  chloride 10.12 

Lithium  chloride 0.43 

Potassium  bromide 1 .  97 

Potassium  iodide 0.01 

Calcium  sulphate 27.00 

Sodium  metaborate small  amount 

Calcium  bicarbonate 31.61 

Sodium  nitrate 0.16 

Sodium  nitrite faint  trace 

Calcium  phosphate faint  trace 

Mangano-manganic  oxide 0.21 

Ferric  oxide  and  alumina 0 .  08 

Silica 105 

Total .      .      .  ■ 522.34 


MINERAL  WATERS  163 


Hathohn  Wate:r,  Saratoga  Springs,  New  York 
One  U.  S.  gallon  contains: 

Solids.  Grains. 

Ammonium  chloride 2.19 

Lithium  chloride 2.60 

Potassium  chloride 19.28 

Sodium  chloride 425.93 

Potassium  bromide 0.40 

Potassium  iodide .      .  0.12 

Sodium  sulphate 0.24 

Sodium  metaborate trace 

Sodium  nitrite trace 

Sodium  bicarbonate 12.81 

Magnesium  bicarbonate 114.53 

Calcium  bicarbonate 179.70 

Barium  bicarbonate 0 .  80 

Strontium  bicarbonate 0 .  55 

Strontium  bicarbonate trace 

Ferric  oxide  and  alumina 0 .  55 

Silica 0.95 


Total 760.10 


Champion  Water,  Saratoga  Springs,  New  York 
One  U.  S.  gallon  contains: 

Solids.  Grains. 

Ammonium  chloride 0.54 

Potassium  chloride      . 5.90 

Sodium  chloride 262.65 

Lithium  chloride 0.31 

Sodium  sulphate 1  •  71 

Potassium  bromide •.      .      .      .  1.16 

Potassium  iodide 0 .  01 

Sodium  metaborate small  amount 

Sodium  nitrate trace 

Sodium  bicarbonate 10.31 

Magnesium  bicarbonate 28.32 

Calcium  bicarbonate 81 .  81 

Barium  bicarbonate 0.69 

Strontium  bicarbonate trace 

Ferric  oxide  and  alumina 0.07 

Mangano-manganic  oxide trace 

Silica      . 0.71 

Total 392.84 


164  HYDROTHERAPEUTICS— MINERAL   WATERS 


Vichy  Water,  Saratoga  Springs,  New  York 
One  U.  S.  gallon  contains: 

Solids.  Grains. 

Ammonium  chloride 0.05 

Potassium  chloride 0.43 

Sodium  chloride 86.94 

Lithium  chloride 0.03 

Potassium  bromide trace 

Potassium  iodide trace 

Sodium  sulphate 1-73 

Sodium  metaborate trace 

Sodium  bicarbonate 48 .  56 

Magnesium  bicarbonate 3 .  52 

Calcium  bicarbonate 8.71 

Ferric  oxide  and  alumina 0.18 

Calcium  sUicate '.      .      .  1 .  60 

Sihca 0.11 


Total 151.96 


MissisQuoi  Springs,  Sheldon,  Vermont 

One  U.  S.  gallon  contains: 

Solids.  Grains. 

Ammonium  chloride trace 

Lithium  chloride trace 

Potassium  chloride 0.20 

Sodium  chloride 0.12 

Sodium  sulphate 1 .  43 

Sodium  metaborate trace 

Calcium  phosphate trace 

Sodium  nitrate trace 

Sodium  bicarbonate 1-06 

Magnesium  bicarbonate ...  4 .  88 

Calcium  bicarbonate 9 .  88 

F'erric  oxide  and  alumina 0. 12 

Mangano-manganic  oxide 0.03 

Calcium  silicate 0.50 

Silica 2.23 

Total 20.40 


MINERAL  WATERS  165 


Londonderry  Lithia  Water,  Londomderry,  New  Hampshire 

One  U.  S.  gallon  contains: 

Solids.  Grains. 

Sodium  chloride 0.03 

Lithium  chloride trace 

Potassium  chloride 0.26 

Ammonium  chloride trace 

Sodium  sulphate 0 .  65 

Sodium  nitrate 0-23 

Sodium  nitrite        trace 

Sodium  bicarbonate 0.42 

iMagnesium  bicarbonate 0.41 

Calcium  bicarbonate 2 .  14 

Ferric  oxide  and  alumina 0 .  02 

Calcium  sihcate 0 .  07 

Silica 0-95 

Total 5.18 


Congress  Water,  Saratoga  Springs,  New  York 

One  U.  S.  gallon  contains: 

Solids.  Grains. 

Ammonium  chloride 1 .  77 

Potassium  chloride 19.78 

Sodium  chloride 248.65 

Lithium  chloride 1 .  89 

Potassium  iodide 0 .  05 

Potassium  bromide 2 .  32 

Sodium  sulphate    .      .            0 .  74 

Sodium  bicarbonate 36.41 

Magnesium  bicarbonate 97.14 

Calcium  bicarbonate 131.03 

Barium  bicarbonate 0 .  77 

Strontium  bicarbonate trace 

Sodium  metaborate trace 

Sodium  nitrite trace 

Ferric  oxide  and  alumina 1-21 

Silica 114 

Total 542  90 


CHAPTER    VJII 

MEDICATIONS 

Hydrochloric  Acid  and  Pepsin. — Hydrochloric  acid  has  always 
been  regarded  as  an  available  therapeutic  agent  in  the 
treatment  of  certain  forms  of  gastritis,  especially  those 
characterized  by  deficiency  of  acid  secretion.  CHnicians, 
however,  have  been  at  variance  in  regard  to  the  quantity 
that  should  be  administered.  Some  have  doubted  the 
advisability  of  giving  it  in  certain  forms  of  subacidity, 
maintaining  that  in  subacid  conditions  pepsin  is  always 
present  and  that  the  therapeutic  requirements  of  the 
patient  can  best  be  met  by  a  carefully  selected  dietary. 
A  small  minority  greatly  restrict  the  administration  of 
hydrochloric  acid  while  at  the  same  time  they  abandon 
the  use  of  pepsin  altogether.  They  argue  that  artificial 
aids  to  digestion  are  not  necessary,  and  that  their  habitual 
use  is  to  a  certain  extent  injurious.  Every  organ,  we  are 
told,  is  strengthened  by  activity  and  weakened  by  lack  of 
exercise. 

The  researches  of  Leo,i  based  upon  the  experiments  of 
Pawlow,  have  thrown  new  hght  upon  hydrochloric  acid  and 
pepsin  as  therapeutic  factors  in  the  treatment  of  anacid  and 
subacid  conditions. 

It  is  important,  when  considering  the  effect  of  hydro- 
chloric acid,  to  take  into  account  how  the  ingested  food 
becomes  mixed  with  the  acid  in  the  stomach.  The  mixing 
varies,  according  to  whether  the  hydrochloric  acid  has  been 
taken  medicinally  or  secreted  by  the  mucous  membrane  of 
the  stomach  itself.  In  artificial  acidification  the  degree  of 
admixture  depends  also  upon  the  interval  of  time  between 

'  Die  Salzsauorcthcrapic  auf  thcorctiHclior  u.  praktiscl^cr  (IniiKllaKe,  Berlin, 
1908. 


HYDROCHLORIC  ACID  AND  PEPSIN  107 

the  ingestion  of  the  nutriment  and  the  administration  of 
the  acid. 

Hydrochloric  acid  may  be  taken  immediately  after  the 
ingestion  of  food,  or  a  few  minutes  later  (10,  15,  20);  by 
giving  small  doses  at  frequent  intervals,  which  is  the  usual 
practice,  the  normal  process  of  secretion  of  hydrochloric  acid 
is  imitated.  Hj'drochloric  acid  taken  by  mouth  after  the 
ingestion  of  food  does  not  become  thoroughly  incorporated 
\\-ith  the  food;  it  penetrates  only  the  upper  layer  of  it,  which 
later  becomes  the  central  portion.  The  chief  bulk,  and  espe- 
cially the  outer  portion  of  the  stomach  contents,  remains  at 
first  unaffected  by  the  acid.  That  portion  of  the  acid  which 
does  not  enter  into  the  food  mixture  is  transported,  because 
of  its  fluidity,  by  the  shortest  possible  route  from  the  cardia 
to  the  pylorus  and  thence  into  the  duodenum. 

Hydrochloric  acid  may  be  taken  during  the  meal.  Its 
admixture  with  the  food  is  probably  accomplished  best 
when  it  is  so  taken,  as  it  can  thus  reach  every  particle. 

Hydrochloric  acid  may  be  taken  in  one  dose,  the  purpose 
being  to  obtain  an  effect  upon  the  food  mass  from  the 
periphery,  as  is  the  case  with  hydrochloric  acid  normally 
secreted.  It  ma}^  be  taken  before  the  commencement  of 
the  meal  if  this  is  to  consist  of  solid  foods  only  or  if  it  is  to 
be  a  small  meal,  such  as  breakfast;  or  directly  after  the  soup, 
should  soup  be  the  first  item  of  the  meal.  The  action  of  the 
natural  secretion  is  most  closely  simulated  when  the  hydro- 
chloric acid  is  administered  in  this  manner,  for  the  acid 
becomes  mixed  with  the  food  mass  from  the  periphery 
toward  the  centre;  it  comes  in  direct  contact  with  the 
mucous  membrane  of  the  stomach,  and  is  able  to  exert  its 
effect  to  the  best  advantage. 

These  methods  of  administering  hydrochloric  acid — 
before  or  during  the  meal,  after  the  meal,  and  in  single 
or  divided  doses — may  be  combined  in  various  ways. 

Hydrochloric  acid  may  be  taken  on  an  empty  stomach, 
independently  of  the  ingestion  of  food;  but  if  the  dose  is  too 
large  or  too  concentrated  harm  may  be  done  to  the  mucous 
membrane  of  both  the  stomach  and  the  intestine. 


168  MEDICATIONS 

By  experiment  it  has  been  found  that  hydrochloric  acid 
taken  internally  has  the  power  to  stimulate  the  secretion 
of  the  ferments  of  the  stomach.  This  is  brought  about  by 
the  action  of  the  acid  on  the  pylorus  producing  a  secretin, 
which  in  turn  being  absorbed  stimulates  the  secretion  of 
gastric  juice.  It  has  also  been  found  that  ingested  hydro- 
chloric acid  will  directlj^  stimulate  the  secretion  of  hydro- 
chloric acid  by  the  depraved  gastric  mucous  membrane,  and 
that  the  ingested  acid  makes  it  possible  for  the  gastric  mu- 
cous membrane  to  respond  with  an  increased  formation  of 
acid  on  the  introduction  of  food.  These  statements  refer 
to  the  pathologically  changed  gastric  mucous  membrane 
only  (subacidity  in  gastritis).  The  direct  stimulation  of 
acid-formation  has  not  been  proved  with  respect  to  normal 
mucous  membrane,  nor  has  it  been  observed  in  achj^lia  gas- 
trica,  a  condition  in  which  the  gastric  mucous  membrane  is 
generall}^  irreparably  altered.  It  can  be  secured  only  when 
the  hydrochloric  acid  comes  in  direct  contact  with  the  gastric 
mucous  membrane.  If  the  amount  of  hydrochloric  acid  ad- 
ministered be  large,  this  effect  will  follow  with  any  method 
of  administration,  even  after  eating.  Hydrochloric  acid 
should  be  given  before  the  meal,  particularly  if  the  doses 
are  small;  this  is  the  surest  way  to  act  on  the  parenchyma 
of  the  stomach. 

Experimental  research  has  shown  that  extensive  proteo- 
lysis cannot  be  obtained  by  the  administration  of  hydro- 
chloric acid  alone;  pepsin  must  be  given  simultaneously.  It 
was  formerly  assumed  that  the  administration  of  pepsin  was 
useless,  since  such  a  small  amount  of  pepsin  is  necessary  for 
proteolysis — for  when  free  h^^drochloric  acid  was  absent, 
some  pepsin  or  its  precursor,  pepsinogen,  was  found  in  the 
stomach,  though  only  in  minute  quantities.  In  order  to 
secure  activity  of  the  pepsin,  or  pepsinogen,  by  the  intro- 
duced hydrochloric  acid,  it  is  necessary  that  these  two  be- 
come mixed;  this  important  fact  has  often  been  totally 
ignored.  In  most  cases  the  mixing  of  hj^drochloric  acid 
and  pepsin  does  not  take  place,  owing  to  the  fact  that 
only  hydrochloric  acid  is  administered,  and,  being   given 


HYDROCHLORIC  ACID  AND  PEPSIN  169 

after  eating,  it  adheres  to  the  top  of  the  stomach  con- 
tents, or  penetrates  into  its  centre,  and  remains  for  the 
most  part  separated  from  the  pepsin  of  the  gastric  mucous 
membrane.  When  during  the  later  stages  of  digestion  a 
certain  mixing  of  the  pepsin  with  the  hydrochloric  acid 
does  take  place,  it  is  insufficient  at  that  time,  owing  to  the 
fact  that  the  greater  part  of  the  free  hydrochloric  acid  has 
formed  stable  combinations.  Proteolysis  begins  immedi- 
ately on  administering  a  mixture  of  pepsin  and  hydrochloric 
acid.  Leo  proved  that  more  or  less  thorough  proteolysis 
took  place,  even  in  patients  with  achylia,  when  pepsin 
and  hydrochloric  acid  were  administered  together.  It 
was  sometimes  impossible  to  detect  macroscopically  any 
difference  between  the  stomach  contents  of  such  patients 
and  of  persons  in  good  health.  Microscopic  examination 
revealed  a  loosening  of  the  protein  covering  of  the  starch 
granules,  as  well  as  of  the  connective  tissue  surrounding 
the  muscular  fibrillse  of  ingested  meat.  The  reaction  of 
the  food  mass  was  acid.  Combined  hydrochloric  acid  could 
always  be  demonstrated,  and  frequently  even  free  hydro- 
chloric acid.  The  total  acidity  was,  as  a  rule,  comparatively 
high.  Albumoses,  and  to  a  less  extent  acid-albumin  and 
peptones,  were  found  in  the  filtrate  of  the  stomach  contents. 
This  condition  was  independent  of  the  time  of  administration 
of  the  hydrochloric  acid,  whether  during  or  after  eating. 

The  administration  of  pepsin  alone  is  of  but  little  thera- 
peutic value.  After  reaching  the  stomach  it  comes  in  contact 
with  the  hydrochloric  acid  at  a  few  points  only — on  the 
outer  border  of  the  stomach  contents — and  can  therefore 
exert  its  proteolytic  action  nowhere  else.  Pepsin  given 
alone  soon  passes  into  the  intestine  without  having  assisted 
materially  in  the  digestion  of  the  food.  It  is  absolutely 
useless  to  prescribe  pepsin  alone  in  cases  in  which  hydro- 
chloric acid  is  not  furnished  by  the  stomach. 

Hydrochloric  acid  assists  the  intestinal  digestion  of  pro- 
tein to  the  extent  that  protein  substances  which  have  been 
treated  previously  with  pepsin  and  hydrochloric  acid  can 
be  digested  much  better  with  trypsin.    Besides  this,  hydro- 


170  MEDICATIONS 

chloric  acid  acts  upon  some  precursor  in  the  duodenum, 
producing  an  intestinal  secretin  or  hormone,  which,  being 
absorbed,  stimulates  the  secretion  of  pancreatic  juice. 

Hj'drochloric  acid,  when  taken  internally,  increases  the 
secretion  of  pancreatic  juice.  This  augmentation  commences 
about  half  an  hour  after  the  introduction  of  the  acid  into  the 
stomach,  and  returns  to  the  normal  after  one  hour. 

Persons  with  normal  or  hyperacid  stomachs  have  con- 
siderable tolerance  for  large  quantities  of  protein.  It  has 
been  found  that  cases  of  achyha  gastrica  which  suffer  from 
the  results  of  excessive  decomposition  of  protein  (gastro- 
genic  diarrhea)  are  protected  from  this  effect  b}^  the 
administration  of  hydrochloric  acid. 

The  change  of  the  pro-enzymes  into  enzymes  is  assisted 
by  hydrochloric  acid.  This  fact  is  of  no  practical  importance, 
however,  for  the  quantity  of  hj^drochloric  acid  secreted  is 
sufficient  in  cases  of  subacidity  for  the  development  of  the 
activity  of  the  enzymes;  in  achyha,  however,  the  pro- 
enzymes, if  present  at  all,  are  present  in  exceedingly  small 
amount. 

It  has  been  shown  that  hydrochloric  acid  taken  by  the 
mouth,  like  the  natural  product,  prolongs  the  stay  of  the 
food  in  the  stomach.  This  is  due  to  a  periodic  closure  of 
the  pylorus  brought  about  by  the  action  of  the  hj'drochloric 
acid  on  the  mucous  membrane  of  the  duodenum,  and  takes 
place  whether  the  hydrochloric  acid  is  given  during  the  meal 
or  afterward. 

It  has  been  noted  that  hydrochloric  acid  is  able  also  to 
stimulate  the  secretion  of  bile. 

When  large  quantities  of  acid  are  given,  the  effect  on  the 
small  intestine  is  the  same  whether  the  acid  be  administered 
before,  during,  or  after  meals.  But  when  small  quantities  are 
given,  it  is  best  to  give  them  before  meals.  Small  quantities 
of  acid,  which  per  se  have  no  direct  effect  whatever  on  the 
gastric  digestion,  may,  when  administered  in  this  manner, 
exert  an  energetic  influence  on  digestion  in  the  small 
intestine. 

Numerous  individual  doses  of  hydrochloric  acid  exert  a 


HYDROCHLORIC   ACID  AND  PEPSIN  171 

favorable  influence  on  the  general  nutrition.  This  has 
been  proved  by  a  general  improvement  of  the  nutrition 
in  cases  of  achyUa  under  hydrochloric  acid  treatment.  It 
is  possible  also  to  diminish  the  percentage  of  carbon  dioxide 
and  the  alkalinity  of  the  blood  by  the  administration  of 
hydrochloric  acid.  When  hydrochloric  acid  is  being  given 
the  respiratory  metabolism  shows  a  decrease  in  the  expendi- 
ture of  oxygen  and  an  increase  in  the  exhalation  of  carbon 
dioxide. 

Ingested  hydrochloric  acid  has  a  favorable  influence  on 
the  appetite;  it  is,  therefore,  a  direct  stomachic.  This 
effect  is  due  to  improvement  in  the  general  nutrition,  and 
to  stimulation  of  the  peripheral  nerve  fibres  which  excite  the 
sensation  of  hunger.  The  acid  is  also  thought  to  stimulate 
the  mucous  membrane  of  the  stomach,  with  resulting 
secretion  of  gastric  juice. 

As  will  be  seen  from  a  consideration  of  these  conclusions, 
hydrochloric  acid  is  indicated  as  an  aid  to  both  gastric  and 
intestinal  function.  It  is  indicated  in  subacidity  and  an- 
acidity  to  replace  the  deficient  secretion  and  thus  assist  the 
proteolytic  process  of  digestion.  Taken  medicinally,  it  exerts 
an  influence  upon  the  pancreatic  secretion  and  upon  the 
secretion  of  bile.  The  influence  on  biliary  secretion  appears 
to  be  independent  of  any  effect  on  gastric  digestion.  Intes- 
tinal digestion  may  be  greatly  improved  by  the  administra- 
tion of  hydrochloric  acid  in  suitable  cases.  Very  frequently 
the  purpose  will  be  to  exert  a  coordinate  action  on  both 
the  stomach  and  the  intestine;  one  favorable  result  of  the 
treatment  with  hydrochloric  acid  will  always  be  an  improve- 
ment in  proteolytic  action. 

According  to  Leo,  hydrochloric  acid  and  pepsin  should 
be  administered  together.  This  investigator  is  convinced 
that  the  failures  with  hydrochloric  acid  which  are  so  fre- 
quently reported  are  due  solely  to  the  fact  of  its  having 
been  administered  without  pepsin. 

A  number  of  preparations  containing  hydrochloric  acid 
are  at  our  disposal.    Two  solutions  of  the  acid  are  official: 


172  MEDICATIONS 

1.  Acidum  hydro chloricum — hydrochloric  acid;  100  parts 
contain  31.9  parts  hydrochloric  acid  and  68.1  parts  water. 

2.  Acidum  hydro  chloricum  dilutum — diluted  hydrochloric 
acid;  100  parts  contain  10  parts  hydrochloric  acid  and  90 
parts  water. 

Hydrochloric  acid  should  be  taken  well  diluted,  through 
a  glass  tube;  otherwise  it  decalcifies  the  tooth  substance 
and  irritates  the  mucous  membrane  of  the  mouth,  pharynx, 
and  esophagus.  For  the  protection  of  health}^  tissue  as 
well  as  the  maintenance  of  comfort  to  the  patient,  suitable 
methods  of  drug  administration  are  demanded;  therefore  the 
author  repeats  a  suggestion  with  regard  to  the  administra- 
tion of  hydrochloric  acid  which  his  personal  experience  has 
shown  meets  the  difficulties.  He  has  employed  this  method 
since  1899.^  In  prescribing  the  acid  it  was  at  first  suggested 
that  it  be  taken  in  gelatin  capsules  (Fig.  21).  It  was  found, 
however,  that  the  acid  penetrated  the  capsule  too  quickly. 
After  repeated  trials  it  was  discovered  that  two  capsules  of 
differing  sizes  (the  smaller  one,  containing  the  acid,  encased 
in  the  larger  one)  would  give  sufficient  thickness  to  obviate 
quick  penetration — would,  in  fact,  retain  the  acid  for  a  long 
time  (Fig.  22).  This  device  gives  the  patient  ample  time 
for  swallowing  and  reduces  to  a  minimum  whatever  annoy- 
ance or  risk  is  involved.  The  double  capsule  is  easily  con- 
structed. The  cap  of  a  No.  "0"  capsule  will  fit  into  the 
body  of  a  Xo.  ''00"  capsule,  forming  with  it  a  shell  of  double 
thickness,  which,  of  course,  offers  a  twofold  resistance  to  the 
action  of  the  acid  (Fig.  23).  The  lower  edge  of  the  cap  of 
the  capsule  is  first  moistened  with  the  tip  of  the  tongue,  so 
that  when  it  is  placed  over  the  body  of  the  capsule  it  be- 
comes immediately  sealed.  The  patient  is  instructed  to  use 
an  ordinary  dropper  for  filling  the  capsule  just  before  tak- 
ing. Such  double-bottom  capsules  hold  1  Cc.  (15  minims) 
of  hydrochloric  acid. 

Additions  of  other  medicinal  agents  (except  pepsin)  to 
hydrochloric  acid  are  not  usual.     To  correct  the  taste,  the 

'  Simple  Method  of  Administoring  Hydrochloric  Acid,  Charles  D.  Aaron, 
Journal  of  the  American  Medical  Association,  June  24,  1S99. 


IIYDEOCIILORIC  ACID  AND  PEPSIN 


173 


acid  can  be  given  to  adults  in  tea,  with  or  without  the 
addition  of  sugar.  For  children  syrup  of  orange  is  a  good 
vehicle. 


Fig.  I'l 


Fig.  22 


Fig.  23 


Single  "00"  gelatin  capsule.         Inner  capsule  in  proper  position. 


Double  capsule  closed. 


Acidol.  —  This  is  a  betain  chlorhydrate,  prepared  from 
molasses,  which  in  watery  solution  splits  up  into  non-toxic 
betain  ftrimethylamine  acetic  acid)  and  hydrochloric  acid. 
It  is  considered  harmless.  Acidol  without  pepsin  is  as 
ineffective  for  good  as  hydrochloric  acid  without  pepsin. 
Combined  with  pepsin  it  has  been  introduced  to  the  pro- 
fession as  acidol-pepsin  tablets.  These  tablets  are  not  so 
efficacious  as  hydrochloric  acid  and  pepsin  in  liquid  form. 
Fortunately  the  National  Formulary  gives  us  a  number  of 
preparations  containing  both  hydrochloric  acid  and  pepsin. 
The  following  is  especially  recommended: 


174  MEDICATIONS 

Gm.  or  Cc. 

I^ — Acidi  hydrochlorici 2.5  n^xl 

Pepsini 21.0  3xvj 

Glycerini 125.0  oiv 

Aquse q.  s.  ad     250.0  oviij 

Misce. 

Sig. — A  teaspoonful  to  a  tablespoonful  in  a  glass  of  water  to  be  taken  during 
meals. 

Pepsin  and  hydrochloric  acid  should  not  be  given  in  an 
alcoholic  menstruum.  Fuld^  concludes  that  alcohol  is  a 
ferment  poison.  Ascher^  has  found  that  various  drugs 
influence  pepsin  digestion.  Iron  is  particularly  detrimental. 
While  the  bitters,  quinine  and  condurango,  are  tonics,  they 
should  not  be  given  with  pepsin,  on  account  of  their  ferment- 
destroying  property.  It  is  not  permissible  to  take  pepsin 
in  hot  liquids,  since  a  higher  than  body  temperature 
destroys  the  activity  of  this  ferment. 

There  are  a  number  of  other  preparations  intended  to 
replace  pepsin  and  hydrochloric  acid.  One  of  these  is  the 
so-called  gasterine,  or  gastric  juice  of  the  dog.  To  obtain 
supplies,  Pawlow  makes  an  opening  into  the  esophagus  of 
the  dog  and  another  into  the  stomach — the  former  to  divert 
the  food  from  its  natural  course  so  that  it  will  not  reach  the 
stomach;  the  latter  for  access  to  the  gastric  juice  as  it  is 
secreted.  The  stomach  having  been  emptied  and  thoroughly 
washed  out,  the  dog  is  offered  meat,  which  in  the  act  of 
swallowing  falls  out  of  the  upper  segment  of  the  esophagus; 
in  the  stomach,  however,  a  copious  secretion  of  gastric  juice 
takes  place.  In  this  manner  about  600  to  800  Cc.  of  gastric 
juice  daily  may  be  obtained  from  a  dog  weighing  17  kilos. 
Pawlow  has  recommended  this  canine  gastric  juice  (gas- 
terine) as  a  medicinal  agent.  Gasterine,  taken  in  daily  doses 
of  250  to  500  Cc,  has  given  good  results  in  cases  of  sub- 
acidity  and  anacidity.  The  cost  of  the  product  at  present 
is  an  obstacle  to  its  general  employment;  besides,  it  is 
somewhat  repulsive.  The  artificial  mixture  of  hydrochloric 
acid  and  pepsin,  fortunately,  serves  the  same  purpose. 

'  Salz.sauere.sekretion  und  Salzsaueretheraiiio,  llierapcutische  IVlonatshofte, 
Berlin,  November,  190S,  p.  549. 

2  Archiv  fiir  VerdauunKs-Kr;inklu'it(Mi,  I'crlin,  Dccciiihcr,  H)()S,  p.  G20. 


PANCREATIN  175 

Another  preparation  intended  to  replace  hydrochloric  acid 
and  pepsin  is  the  so-called  dyspeptine  of  Hepp.  This  is 
the  gastric  juice  of  pigs,  obtained  in  a  manner  similar  to 
that  just  described.  But  it  has  been  found  that  dyspeptine 
contains  no  hydrochloric  acid  whatever,  that  it  does  not 
digest  protein,  and  is,  the;refore,  therapeutically  inactive. 

The  quantity  of  hydrochloric  acid  to  be  prescribed  depends 
upon  the  object  to  be  attained.  Small  quantities  suffice 
when  it  is  intended  to  stimulate  the  gastric  and  intestinal 
mucous  membrane,  the  stomach  being  empty.  If,  on  the 
other  hand,  copious  proteolysis  is  wanted,  large  quantities 
of  hydrochloric  acid  are  necessary.  It  may  be  stated  as 
a  general  rule  that,  as  has  been  shown  experimentally,  the 
ingestion  of  large  quantities  of  food  causes  the  secretion  of 
large  quantities  of  acid;  and  the  physiologic  proportion 
holds  with  smaller  quantities.  Foods  with  varying  propor- 
tions of  proteins  require  varying  quantities  of  hydrochloric 
acid;  for  example,  bread  requires  less  hydrochloric  acid  and 
more  pepsin  than  meat.  It  has  been  calculated  that  the 
normal  stomach  produces  for  a  mixed  meal  about  150  Cc. 
(5  ounces)  of  the  official  hydrochloric  acid.  Of  course  it  is 
rarely  possible  to  administer  such  large  quantities.  Doses 
proportionally  much  smaller  than  the  quantity  of  hj^dro- 
chloric  acid  normally  secreted  are  given  when  hj^drochloric 
acid  is  prescribed  medicinally. 

It  follows  from  the  statements  made  at  the  beginning 
of  this  chapter  that  the  time  of  taking  the  hydrochloric 
acid  must  depend  on  the  purpose  sought.  The  contents  of 
the  stomach  are  influenced  best  if  hydrochloric  acid  is 
taken  during  the  meal  as  a  beverage;  taken  after  food, 
however,  it  also  acts  well  in  this  respect.  Both  methods 
may  be  combined.  Shortly  before  eating  is  the  best  time  for 
taking  the  acid  for  its  effect  on  the  gastric  mucous  membrane 
itself.  The  effect  on  the  small  intestine  is  also  best  obtained 
by  small  doses  before  meals;  if  the  acid  be  taken  during  the 
meal,  larger  doses  are  required  for  this  purpose. 

Pancreatin. — The  other  important  digestive  ferment  recog- 
nized by  the  U.  S.  P.  is  pancreatin.     The  official  pancreatin 


176  MEDICATIONS 

possesses  the  property  of  converting  twenty-five  times 
its  own  weight  of  starch  into  substances  soluble  in  water. 
Pancreatin  should  contain  the  pancreatic  ferments:  Trj^psin, 
which  digests  proteins;  steapsin,  which  emulsifies  fats;  amyl- 
opsin,  which  converts  starch  into  sugar;  and  a  milk-curdling 
ferment.  Hare  describes  a  method  by  which  pancreatin 
may  be  made  by  the  physician.  The  pancreas  of  a  pig 
which  has  been  killed  about  six  hours  after  a  full  meal, 
when  the  organ  is  in  an  active  state  is  chopped  up  finely  and 
placed  in  four  times  its  weight  of  dilute  alcohol  and  allowed 
to  stand  twelve  hours;  the  alcohol  is  then  decanted  or  fil- 
tered off.  The  filtrate  is  administered  in  doses  of  4  to 
8  Cc.  (1  to  2  drams).  It  may  also  be  prepared  as  follows: 
Wash  and  chop  finely  the  fresh  pancreas,  and  allow  the 
gland  to  soak  in  absolute  alcohol  twenty-four  to  forty-eight 
hours.  The  alcohol  is  then  squeezed  out  and  to  the  gland 
is  added  ten  times  its  weight  of  glycerin.  The  mixture 
must  stand  forty-eight  hours  and  then  be  filtered.  The 
dose  is  2  Cc,  (30  minims).    It  may  be  given  in  milk. 

Pancreatin  has  marked  digestive  properties;  in  addition 
to  its  action  on  protein  it  converts  all  starches  into  sugar, 
emulsifies  fat,  and  curdles  milk.  It  is  especially  indicated 
when  the  stomach  is  deficient  in  secreting  power.  Often  the 
gastroenterologist  finds  it  necessary  to  treat  the  stomach  as 
though  it  were  a  part  of  the  duodenum.  In  all  cases  of 
subacidity  and  achylia,  duodenal  digestion  must  make  up 
the  deficiency  in  gastric  digestion.  Patients  who  for  years 
have  had  no  severe  or  markedly  distressing  gastric  symp- 
toms may  suddenly  be  seized  with  a  diarrhea,  due  to 
insufficient  secretion  of  gastric  juice.  When  the  diarrhea 
(gastrogenic,  as  it  has  been  called)  once  develops,  the  irrita- 
bility of  the  duodenum  should  be  reheved  as  much  as  pos- 
sible. The  condition  may  be  aggravated  by  either  gas- 
tric hypermotihty  or  pyloric  insufficiency.  If  pancreatic 
digestion  be  instituted  in  the  stomach,  the  duodenum  will 
receive  the  food  in  a  more  or  less  digested  state,  and  in 
this  way  irritation  by  fermenting  foods  may  be  largely 
obviated.     Relieved  of   tlic   irritation,  the  intestine,  as  a 


PANCREATIN  177 

rule,  soon  regains  its  lost  tone.  In  cases  in  which  hydro- 
chloric acid  and  pepsin  are  not  indicated,  but  some  digestant 
is  required,  pancreatin  fulfils  most  nearly  the  requirements. 
It  is  especially  indicated  in  chronic  gastric  catarrh  associated 
with  the  secretion  of  much  mucus.  In  these  cases  hydro- 
chloric acid  precipitates  the  mucin  from  the  mucus,  and  a 
coating  is  formed  around  the  whole  food  mass — so  digestion 
is  interfered  with  instead  of  being  promoted.  Pancreatic 
preparations  should  always  be  given  with  alkalies,  since  the 
alkalies  in  solution  in  the  stomach  dissolve  mucus.  Pan- 
creatic preparations  are  particularly  valuable  in  achylia 
gastrica. 

Brammel^  reports  an  instance  which  illustrates  the  im- 
portance of  the  pancreatic  enzymes  and  their  relation  to 
normal  development  and  growth.  The  patient  was  a  youth 
of  nineteen  years  whose  bodily  development  had  apparently 
been  arrested  about  the  age  of  eleven  years.  He  was  bright 
and  intelligent,  perfectly  formed,  and  presented  none  of  the 
physical  alterations  suggestive  of  sporadic  cretinism.  He 
had  suffered  for  many  years  from  diarrhea.  The  urine  was 
free  from  sugar.  From  careful  investigation  it  was  concluded 
that  the  pancreatic  secretion  was  defective  or  completely 
absent;  and  that  this  was  the  case  was  proved  by  the 
remarkable  improvement  brought  about  by  administering 
a  glycerin  extract  of  pancreas.  In  two  years  he  grew  five 
inches  and  increased  22  pounds  in  weight,  in  spite  of  the 
fact  that  for  eight  years  he  was  said  not  to  have  grown  at 
all.  In  the  same  work  is  reported  a  case  of  a  girl  of  eighteen 
years  who  had  not  grown  for  seven  years  and  who  had  been 
troubled  all  her  life  with  diarrhea.  She  also  was  treated 
with  pancreatic  extract,  with  the  result  that  she  increased 
nine  and  one-half  pounds  in  weight  and  added  almost  two 
inches  to  her  height  in  a  little  over  four  months.  There 
was  also  a  marked  improvement  in  her  general  condition. 

Various  preparations  of  pancreas  have  been  placed  before 
the  profession  under  trade  names.  Pankreon  is  a  preparation 
of  pancreatin  containing  10  per  cent,  of  tannic  acid.     It  is 

1  The  Pancreas:  its  Surgery  and  Pathology,  Robson  and  Cammidge,  p.  131. 
12 


178  MEDICATIONS 

insoluble  in  acid  media,  but  is  split  up  by  alkalies;  it 
therefore  passes  through  the  stomach  unchanged,  exerting 
its  digestive  power  in  the  intestine.  The  best  prepara- 
tion for  us  is  the  liquor  pancreaticus  of  the  National 
Formulary: 

P.i^XREATIC   SOLrXIOX 

Gm.  or  Cc. 

Pancreatin  (U.  S.  P.  ) 4.38  gr.  Ixvj 

Sodium  bicarbonate 12.5  oiij 

Glycerin 62.5  Sij 

Compound  spirit  of  cardamom  (X.  F.)    .      .      .  8.7  oij 

Alcohol 8.7  oij 

Purified  talc  (U.  S.  P.) 3.7  oj 

Water,  a  sufficient  quantity  to  make       .      .      .  250.0  Sviij 

The  dose  should  be  a  tablespoonful  after  each  meal. 

Papayotin  or  papain,  obtained  from  the  juice  of  the 
Carica  papaj-a  tree,  is  a  digestant  that  is  frequentl}"  used. 
It  is  said  to  act  in  both  alkaUne  and  acid  media. 

Pineapple  juice  is  said  to  possess  the  power  of  assisting 
in  the  digestion  of  proteins.  Boihng  or  heating,  as  in  the 
process  of  canning  pineapples,  destroys  the  digestive  power 
of  the  juice.  Taken  raw  or  in  the  natural  state,  this  ferment 
is  active  in  either  acid  or  alkaline  media  but  not  in  neutral 
solutions. 

The  diastatic  ferments  are  suggested  in  those  cases  in 
which  there  is  defective  secretion  of  these  normal  enzj-mes. 
The  ptyalin  of  the  saliva,  however,  is  rarely  absent.  TSlien 
diastase  is  indicated,  the  best  form  of  this  ferment  seems  to 
be  that  present  in  pancreatin.  Vegetable  diastase,  as  found 
in  extract  of  malt,  is  sometimes  employed.  There  are 
also  available  many  proprietary  preparations  of  animal  and 
vegetable  diastases.  Diastase  should  always  be  prescribed 
with  alkalies,  since  the  acid  in  the  stomach  destroys  its  action, 
while  the  alkali  prolongs  amylolysis.  The  giving  of  dias- 
tatic ferments  does  not  remove  the  cause,  and  therefore  is 
not  resorted  to  as  often  as  formerly. 

Alkalies. — While  the  administration  of  hydrochloric  acid 
for  therapeutic  purposes  dates  from  the  discovery  of  the 
fact  that  the  acidity  of  the  gastric  juice  is  due  to  hydro- 


ALKALIES  179 

chloric  acid  (Bidder  and  Schmidt,  1852),  the  administration 
of  alkahes  has  been  practiced  since  an  early  period  in  the 
history  of  medicine.  It  has  long  been  known  that  alkahes 
exert  a  beneficial  influence  over  certain  diseases  of  the 
stomach.  The  first  definite  work  in  investigating  their 
therapeutic  effect  was  that  of  Claude  Bernard,  who  found 
that  small  doses  of  alkalies  stimulated  gastric  secretion  in 
animals,  while  large  doses  had  no  apparent  effect  but  to 
neutralize  the  acidity  of  the  gastric  juice.  Leube,  experi- 
menting with  dogs,  announced  that  bicarbonate  of  soda  as 
present  in  Carlsbad  water  would  not  only  neutralize  gastric 
hyperacidity,  but  would  stimulate  the  gastric  mucous  mem- 
brane to  renewed  and  permanent  secretion  of  gastric  juice 
when  pathologic  changes  had  taken  place  in  the  gastric 
mucosa.  The  medical  profession  is  indebted  to  Jaworski 
for  the  first  exact  knowledge  of  the  action  of  alkalies  on 
the  secretions  of  the  human  stomach.  Jaworski  taught 
that  small  doses  of  alkalies  possess  the  power  of  neu- 
tralizing part  of  the  acidity  of  the  gastric  contents, 
which  effect  is  soon  counteracted,  however,  by  an  in- 
creased secretion  of  hydrochloric  acid.  Sodium  bicar- 
bonate and  Carlsbad  salts,  when  administered  in  small 
doses,  stimulate  gastric  secretion,  while  in  large  doses 
they  exercise  an  inhibitory  effect.  According  to  Mitchell 
Bruce,  alkalies  taken  into  the  mouth  check  for  the  time 
being  the  secretion  of  saliva  and  impair  the  appetite; 
reaching  the  stomach  just  before  meals  they  act  as  stom- 
achics, being  natural  stimulants  to  the  gastric  glands  and 
at  the  same  time  sedative  to  the  nerves.  Sodium  bicarbo- 
nate is  preferred  to  the  potassium  salt  in  disturbances  of 
the  stomach  when  there  is  much  pain  and  a  tendency  to 
nausea  accompanied  by  a  gouty  or  rheumatic  diathesis.  Its 
more  powerful  action  is  said  to  be  due  chiefly  to  the  fact 
that  it  is  more  slowly  absorbed.  It  is  more  commonly 
given  than  the  other  alkalies,  in  doses  of  0.5  to  1  Gm.  (7 
to  15  grains)  shortly  before  meals.  A  portion  of  the  bicar- 
bonate becomes  converted  into  sodium  chloride,  in  which 
form  it  assists  in  the  digestion  of  protein.     Sodium  bicar- 


180  MEDICATIONS 

bonate  liquefies  tenacious  mucus,  thus  enabling  the  gastric 
juice  to  reach  the  food  more  readily.  Sodium  chloride  in 
large  doses  is  a  safe  and  easily  available  emetic.  In  the 
alimentary  canal  the  sulphate  and  the  phosphate  of  soda 
act  as  hydragogue  purgatives  by  virtue  of  their  immediate 
local  action.  They  also  act  as  stimulants  to  the  intestinal 
glands,  and  are  being  constantly  absorbed  and  excreted, 
reabsorbed  and  reexcreted,  in  their  course  along  the  bowel. 
Dr.  Eustace  Smith^  declares  that  disturbances  are  hkely 
to  arise  from  the  prolonged  administration  of  the  alkahes. 
He  distinguishes  between  antacids  and  alkaline  drugs:  the 
former  act  as  alkalies  in  the  stomach  by  neutralizing  acids, 
the  latter  increase  the  alkalinity  of  the  blood  and  tend  to 
render  the  urine  alkaline.  Among  the  principal  antacids 
are  calcium  carbonate,  lime  water,  magnesia,  and  sodium 
bicarbonate ;  the  drugs  used  to  render  urine  alkaline  are  the 
alkaline  potassium  salts,  such  as  the  acetate,  bicarbonate, 
and  citrate.  This  same  writer  advises  that  the  dose  of  an 
antacid,  if  given  three  times  a  day,  should  be  small,  and 
also  that  it  be  discontinued  as  soon  as  it  ceases  to  be  bene- 
ficial. Given  in  large  quantities  on  an  empty  stomach,  the 
antacids  tend  to  increase  the  secretion  of  hydrochloric  acid, 
and  if  the  stomach  be  stimulated  day  after  day  to  com- 
bat this  unnatural  alkalinity  the  result  may  be  such  an 
impairment  of  the  power  of  the  secreting  glands  as  to 
seriously  affect  digestion.  Furthermore,  the  long-continued 
use  of  most  alkalies  is  apt  to  be  followed  by  an  increase  in 
the  alkalinity  of  the  blood,  modification  of  secretions, 
increased  waste,  and  anemia.  The  physician  should  be  on 
his  guard  against  the  unduly  prolonged  administration  of 
either  the  potassium  or  the  sodium  salts.  When  hyper- 
acidity or  hyperchlorhydria  can  be  traced  to  too  rapid 
eating,  to  eating  excessive  quantities  of  meat  or  highly 
seasoned  foods,  to  the  use  of  condiments,  to  nervous  irrita- 
bility, high  tension,  or  worry,  it  is  better  treated  by  elimi- 
nating the  cause  of  the  trouble  than  by  prescribing  a 
corrective  of  the  symptoms.    Temporarj'^  roliof  may  always 

1  British  Medical  .Journal,  .lamiary  \W,  1!)()'.». 


ALKALIES  181 

be  afforded  in  such  conditions  by  the  administration  of  an 
antacid,  as  1  Gm.  (15  grains)  of  sodium  bicarbonate.  Such 
treatment  is,  however,  purely  symptomatic,  and  should  be 
employed  only  while  the  diagnosis  is  being  made  or  while 
the  patient's  habits  of  life  are  being  adjusted.  If  sodium 
bicarbonate,  which  is  undoubtedly  the  best  of  all  antacids, 
be  given  three  times  a  day,  before  meals,  the  dose  should 
be  smaller — half  the  quantity  mentioned.  If  gastritis  be 
present,  bismuth  subnitrate  should  be  given  along  with  the 
antacid. 

Among  the  alkalies  the  Carlsbad  waters  or  those  of  the 
Congress  and  Hathorn  Springs  of  Saratoga,  N.  Y.,  and  the 
Bedford  Springs  in  Pennsylvania  come  in  for  consideration. 
The  chemical  analysis  of  these  waters  is  to  be  found  on 
page  159.  The  artificial  Carlsbad  salt  constitutes  an  effi- 
cient substitute  for  the  more  expensive  natural  salt.  The 
composition  of  the  artificial  salt  is  as  follows  (German 
Pharmacopoeia) : 

Sodium  sulphate,  dry ,     .      .  44  parts 

Potassium  sulphate 2  parts 

Sodium  chloride 18  parts 

Sodium  bicarbonate 36  parts 

This  salt  may  be  administered  in  doses  of  one  to  two 
dessertspoonfuls  in  half  a  pint  of  water,  in  hyperchlorhydria, 
hypersecretion,  or  gastric  ulcer,  the  purpose  being  to  neu- 
tralize the  excessive  secretion  of  hydrochloric  acid.  It  has 
been  used  with  greater  or  less  success  in  gastritis,  though 
Hemmeter  declares  that  he  has  not  seen  an  instance  of 
subacidity  or  achylia  in  which  the  gastric  secretion  ever 
returned  after  being  lost,  or  increased  when  deficient.  The 
therapeutic  use  of  alkalies  appears  to  be  limited  to  stomach 
diseases  associated  with  an  increased  secretion  of  hydro- 
chloric acid,  hyperacidity  from  neurasthenic  causes,  hyper- 
secretion, or  gastric  ulcer.  As  a  means  of  dissolving  adherent 
mucus,  as  well  as  neutralizing  acids,  in  the  process  of  cleans- 
ing the  stomach  by  lavage,  the  alkalies,  including  Carlsbad 
salt  or  waters,  play  a  very  important  role. 


182  MEDICATIONS 

The  best  time  for  the  administration  of  alkahes  in 
hyperacidity  is  from  one-half  to  one  hour  after  meals,  at 
the  height  of  digestion.  The  subjective  symptoms  of  the 
patient,  as  gastralgia,  eructation,  pyrosis,  distention,  consti- 
tute very  good  guides  as  to  the  proper  time  for  administering 
the  alkali.  Owing  to  the  variable  quantity  of  hydrochloric 
acid  found  in  the  stomach  in  the  absence  of  food  in  cases  of 
hypersecretion,  alkalies  should  be  administered  before  meals 
in  such  cases,  in  order  to  insure  salivary  digestion  in  the 
stomach.  Amylolysis  may  be  greatly  assisted  by  the 
administration  of  a  glass  of  Saratoga,  Vichy,  or  sodium 
bicarbonate  solution,  4  Cc.  (1  drachm)  to  one-half  pint  of 
water,  before  meals. 

The  alkalies  are  commonly  divided  into  two  groups — (1) 
alkaline  earths;  (2)  alkaline  carbonates.  Of  the  alkaline 
earths,  magnesium  oxide  or  calcined  magnesia  is  perhaps 
most  important,  as  well  as  being  the  one  that  is  generally 
employed  when  alkahes  are  indicated.  Magnesium  oxide 
is  prepared  by  exposing  magnesium  carbonate  to  a  dull  red 
heat.  It  is  a  white,  very  light  powder,  sparingly  soluble  in 
water.  The  dose  is  0.3  to  2  Gm.  (5  to  30  grains),  repeated  if 
necessary.  In  selecting  an  alkali,  that  which  liberates  the 
least  amount  of  carbon  dioxide  in  the  neutralization  process 
should  be  chosen,  inasmuch  as  the  distention  of  the  weak 
muscular  walls  of  the  stomach  by  gas  is  very  annoying  to 
the  patient,  not  to  say  dangerous  on  account  of  the  pressure 
exerted  in  the  region  of  the  heart.  Of  these  alkalies,  mag- 
nesium oxide  or  the  light  calcined  magnesia  occupies  the 
first  place.  The  chemical  reaction  that  takes  place  when 
magnesium  oxide  is  brought  in  contact  with  free  hj'dro- 
chloric  acid  in  the  stomach  is  expressed  as  follows: 

MgO  +  2HC1  =  MgCl^  +  H,0 

Belonging  to  the  alkaline  carbonates  are  sodium  carbonate 
and  sodium  bicarbonate.  Sodium  l)icarbonate  combines 
with  hydrochloric  acid  so  as  to  form  sodium  chloride,  water, 
and  carbon  dioxide.    The  chemical  equation  is  as  follows: 

NaHCOa  +  HCl  =  NaCI  +  H,0  +  CO, 


BISMUTH  183 

Boas  calculates  the  dose  of  sodium  bicarbonate  necessary 
to  counteract  a  hyperacidity  exceeding  2'>  parts  in  1000  to 
be  8  to  10  Gm.  (oij-iiss);  of  magnesium  oxide  to  offset  the 
same  degree  of  acidity,  3  Gm.  (45  grains). 

In  treating  hyperacidity  or  hypersecretion  the  magnesium 
salts  are  to  be  preferred  to  the  other  alkalies,  especially  when 
constipation  and  flatulence  are  pronounced. 

Bismuth. — The  bismuth  preparations  are  derived  from  the 
metal  itself.  Among  the  salts  used  most  commonly  in  the 
treatment  of  gastric  affections  are  (1)  bismuth  subnitrate, 
(2)  bismuth  salicylate,  (3)  the  subcarbonate  of  bismuth, 
and  (4)  bismuth  subgallate.  Bismuth  subnitrate  is  a  white, 
odorless  powder,  with  a  high  specific  gravity,  insoluble  in 
water,  and  very  faintly  acid.  The  usual  dose  is  0.3  to 
1.2  Gm.  (5  to  20  grains).  It  may  be  employed,  however, 
in  much  greater  quantity  for  the  purpose  of  rendering  the 
stomach  or  intestinal  canal  opaque  for  Roentgenography, 
though  the  subcarbonate  is  better. 

The  salicylate  of  bismuth  is  prepared  by  the  interaction 
of  bismuth  nitrate  and  sodium  salicylate.  It  is  obtained  as 
a  whitish  and  amorphous  powder  insoluble  in  water,  and  is 
administered  in  doses  ranging  from  0.3  to  1.2  Gm.  (5  to 
20  grains). 

The  subcarbonate  of  bismuth  is  the  result  of  a  chemical 
reaction  between  bismuth  nitrate  and  ammonium  carbonate. 
It  also  occurs  as  a  heavy  white  powder,  insoluble  in  water. 
The  dose  is  0.3  to  1.2  Gm.  (5  to  20  grains). 

Bismuth  subgallate  is  a  fine,  bright  yellow  powder,  odor- 
less, unaffected  by  exposure  to  light.  Internally  it  is  recom- 
mended in  gastric  fermentation  associated  with  diarrhea. 
The  dose  is  0.3  to  0.6  Gm.  (5  to  10  grains). 

The  bismuth  salts  are  all  insoluble  in  the  stomach,  where 
they  exert  a  sedative  and  astringent  action,  either  by  their 
effect  upon  the  nerve  endings  or  the  bloodvessels  in  the 
stomach  walls  or  by  coating  the  mucous  membrane.  They 
are  used  more  or  less  extensively  in  the  treatment  of  vomit- 
ing and  pain  due  to  gastric  catarrh  or  to  irritants  such  as 
alcohol.     They  constitute  important  therapeutic  agents  in 


184  MEDICATIONS 

the  treatment  of  gastric  ulcer  and  gastric  carcinoma.  These 
salts  often  exert  a  favorable  influence  on  so-called  nervous 
or  reflex  vomiting  in  cases  of  pregnancy  or  hysteria  with 
true  gastritis. 

Bismuth  salts  were  early  known  to  be  efficacious  in 
gastric  diseases.  They  were  at  one  time  abandoned  on 
account  of  the  frequency  with  which  poisoning  resulted, 
due  to  impurities,  for  the  most  part  from  arsenic.  Since, 
however,  by  improved  methods  of  manufacture,  an  abso- 
lutely uninjurious  drug  has  been  produced,  the  bismuth 
salts  are  again  widely  employed — for  both  their  anodyne 
and  their  antacid  effects.  They  ameliorate  or  promptly 
relieve  pains,  cramps,  burnings,  and  sensations  of  weight, 
referable  to  the  stomach.  In  certain  forms  of  gastric  neu- 
rosis, such,  for  example,  as  nervous  dyspepsia  and  gastric 
crises  of  central  origin,  any  relief  obtained  by  the  adminis- 
tration of  bismuth  is  at  best  only  temporary.  The  bismuth 
salts,  especially  bismuth  subnitrate,  are  among  our  best 
agents  in  the  treatment  of  gastric  ulcer;  owing  to  the 
soothing  and  astringent  influence  which  they  exert,  the 
lesion  is  in  many  instances  healed.  The  subnitrate  of  bis- 
muth seems  to  exert  a  very  marked  influence  upon  such 
reflex  symptoms  as  retching,  vomiting,  and  eructations. 
The  drug  has  been  employed  with  advantage  in  hema- 
temesis. 

According  to  Lyon^  there  is  only  one  contraindication  to 
the  administration  of  the  bismuth  salts,  and  that  is  stenosis 
of  the  intestinal  canal,  wherever  situated.  The  tendency  to 
constipation  alleged  to  be  caused  by  bismuth  may  bo  easily 
overcome  by  olive  oil  enemata.  In  fact,  the  prolonged  use 
of  bismuth  has  been  attended  by  looseness  of  the  bowels — 
a  result  which  may  be  corrected  by  suspending  the  treat- 
ment for  a  time.  The  salicylate  of  bismuth  is  a  valuable 
antifermentative. 

It  is  assumed  that  bismuth  subnitrate  liberates  some  of 
its  nascent  nitric  acid,  which  acts  as  an  astringent  and 
antiseptic  on  the  mucous  membrane  of  the  gastro-intestinal 

'  Archives  des  maladies  de  I'appareil  digestif,  1909. 


BISMUTH  185 

tract.  The  inefficiency  of  bismuth  subcarbonate  is  supposed 
to  be  due  to  the  absence  of  this  acid.  Bismuth  forms  a 
protective  layer  over  gastric  erosions  and  ulcers,  thus  pre- 
venting existing  lesions  from  coming  in  direct  contact  with 
the  acid  gastric  juice. 

Rodari^  has  made  experimental  and  clinical  investigations 
into  the  indications  for  the  bismuth  preparations  in  gastric 
affections,  and  gives  his  results  as  follows : 

1.  Bismuth  subnitrate  is  indicated  not  only  to  furnish  a 
mechanical  protection  to  lesions  (ulcers,  erosions),  but  also 
whenever  it  is  desired  to  produce  inhibition  of  secretion,  as 
in  ulcers,  erosions,  primary  and  secondary  gastritis  acida, 
and,  under  certain  circumstances,  nervous  hyperchlorhydria. 
The  intensity  of  the  reduction  of  gastric  secretion  is  dependent 
upon  the  condition  of  the  mucous  membrane;  the  healthy 
mucosa  reacts  with  a  relatively  slight  inhibition.  Thus  it 
is  explained  that  the  effect  is  more  prompt  in  inflamma- 
tory conditions  than  in  a  neurogenous  increase  of  secretion 
with  a  normal  mucosa.  The  astringency,  upon  which  the 
secretory  reduction  depends,  also  produces  a  kind  of  simul- 
taneous local  antiphlogistic  effect.  In  subacid  conditions, 
when  it  is  desired  to  stimulate  secretion  for  therapeutic 
purposes,  bismuth  subnitrate  is  contraindicated. 

2.  Bismuth  bisalicylate  and  bismuth  salicylate  are  appli- 
cable when  the  gastric  secretion  is  to  be  stimulated — that  is, 
in  subacid  conditions.  The  sahcylic  acid  that  is  liberated  as 
the  salicylates  decompose,  exerts  also  an  antiseptic  effect. 
Hydrochloric  acid  secretion  is  stimulated  by  the  salicylates 
of  bismuth;  therefore,  much  the  same  as  by  the  use  of  the 
saline  mineral  waters.  In  conditions  of  hyperacidity  the 
use  of  these  preparations  is  contraindicated;  they  might 
possibly  be  given  as  antiferments,  on  account  of  the  sali- 
cyhc  acid  they  contain,  but  this  would  lead  to  increased 
secretion  of  hydrochloric  acid  and,  with  it,  to  an  undesirable 
vicious  circle. 

3.  Bismuth  bitannate  has  a  twofold  effect  upon  the  gastric 
mucous  membrane — the  glands  and  the  secretion.     If  the 

1  Magen  unci  Darmkrankheiten,  Zweite  Auflage,  p.  137. 


186  MEDICATIONS 

mucosa  is  intact  and  uninflamed,  the  liberated  tannin  will 
produce  increased  secretion;  if  swollen  and  inflamed,  there 
will  be  a  tj^Dical  inhibition  of  secretion.  Thus,  on  the  one 
hand,  the  preparation,  like  bismuth  salicylate,  appears  to  be 
indicated  when  it  is  intended  to  stimulate  impaired  secretion, 
as  for  instance  in  subacid  conditions  of  a  non-inflammatory 
nature,  but  then  only,  and  not  in  subacid  gastritis;  on  the 
other  hand,  its  application  seems  indicated,  hke  that  of 
bismuth  subnitrate,  in  primary  or  secondary  superacid 
gastric  conditions. 

If  the  bismuth  preparations  are  to  be  administered  for 
any  length  of  time,  for  the  purpose  of  obtaining  a  positive 
therapeutic  effect,  their  indication  or  contraindication  can 
only  be  estabhshed  by  a  functional  examination  of  the 
stomach,  which  is  most  conveniently  done  by  administering 
an  Ewald  test  breakfast. 

Bismuth  subcarbonate  can  hardly  be  expected  to  exert  any 
other  than  a  mechanical  effect  upon  the  injured  mucosa, 
because  under  the  influence  of  hydrochloric  acid  it  spUts 
up  in  the  stomach  into  bismuth  oxychloride  and  carbon 
dioxide,  the  former  an  indifferent  product  and  the  latter 
non-astringent.  Thus  it  seems  illogical  to  combine  this 
medication  with  an  alkahne  salt;  in  fact,  it  seems  wrong 
to  combine  the  other  bismuth  preparations  with  an  alkaline 
salt,  because  the  action  of  these  bismuth  preparations 
depends  upon  the  effect  of  the  hberated  acid.  If  an  alkaline 
salt  were  present,  it  would  unite  with  the  acid  and  thereby 
render  it  ineffective.  On  this  account,  Rodari  says,  com- 
binations of  bismuth  subnitrate  with  magnesium  oxide  and 
sodium  bicarbonate,  which  are  frequently  used  in  practice, 
should  not  be  given  when  the  astringent  effect  of  the  bis- 
muth is  desired. 

Strychnine  and  the  Bitters. — Strychnine  sulphate  is  prepared 
from  nux  vomica.  It  occurs  in  colorless,  odorless,  prismatic 
crystals,  and  has  an  intensely  bitter  taste.  It  is  sparingly 
soluble  in  cold  water,  more  soluble  in  boihng  water.  The 
dose  is  0.001  to  0.003  Gm.  U(^  to  v^d  grain).  Strychnine 
and  nux  vomica  possess  the  properties  of  stomachics.    The 


STRYCHNINE  AND  THE  BITTERS  187 

so-called  vegetable  bitters  or  stomachics  taken  into  the 
mouth  stimulate  the  nerves  of  taste,  producing  thereby 
several  reflex  effects  which  are  of  prime  importance  in  the 
promotion  of  digestion.  The  flow  of  saliva  is  increased,  to 
the  advantage  of  diastatic  digestion,  and  the  vessels  and 
glands  of  the  stomach  are  excited  through  the  central 
nervous  system.  The  effect  on  gastric  secretion  is  said  to 
be  much  more  marked  if  the  bitter  be  aromatic,  so  that  it  is 
relished  by  the  patient. 

Bitters  are  divided  into  two  classes — simple  and  complex. 
Simple  bitters  depend  upon  their  bitterness  alone  for  their 
activity.  The  complex  bitters,  which  include  strychnine  and 
quinine,  in  addition  to  their  local  effect,  act  as  stimulants 
to  other  portions  of  the  gastro-intestinal  membrane.  Ca- 
lumba  is  an  example  of  the  first  class.  Probably  the  best 
type  of  the  second  class  is  nux  vomica  or  its  alkaloid 
strychnine.  Strychnine  is  particularly  useful  as  a  means  of 
stimulating  the  musculature  and  tone  of  the  stomach.  It 
increases  the  appetite  and  vital  powers,  as  well  as  the  senses 
of  sight  and  hearing.  The  respiratory,  cardiac,  and  vaso- 
motor centres  likewise  share  in  the  stimulation.  Arterial 
pressure  is  raised  and  the  pulse  rate  lowered.  Strychnine 
stimulates  peristalsis  to  such  an  extent  at  times  as  to  pro- 
duce diarrhea.  The  drug  is  slowly  absorbed  from  the 
stomach,  but  fairly  rapidly  by  the  rectum.  Owing  to  its 
slow  absorption  and  slow  elimination,  the  administration  of 
strychnine  should  be  interrupted  at  intervals,  to  avoid  cumu- 
lative effect.  Strychnine  sulphate  or  nitrate  may  be  used 
advantageously  with  iron  and  administered  hypodermically, 
as  described  on  page  240.  Tincture  of  nux  vomica  has  been 
found  more  satisfactory  than  strychnine  in  the  treatment  of 
atony  of  the  stomach,  beginning. with  0.3  Cc.  (5  minims), 
gradually  increasing  the  dose  daily  until  the  physiologic 
action  of  the  drug  becomes  visible  by  the  muscular  twitch- 
ings. 

In  pyloric  insufficiency  large  doses  of  strychnine  may  be 
given,  beginning  with  small  doses  and  gradually  increasing 
until  0.01  Gm.  (i  grain)  can  be  given  three  times  a  day. 


188  MEDICATIONS 

The  alkaloid  is  useful  in  the  treatment  of  gastralgia.  in  which 
condition  0.001  Gm.  (15V  grain)  of  the  sulphate  may  be  given 
hypodermically. 

The  primary  effects  of  nux  vomica  and  strychnine  are 
exerted  upon  the  nervous  system,  where  the  drug  acts  as  an 
excitant  to  the  spinal  cord  in  its  motor  tracts. 

The  class  of  bitters  includes  also  such  drugs  as  calumba, 
quassia,  cinchona,  gentian,  orange,  and  condurango.  A  dis- 
tinction has  been  drawn,  as  abeady  stated,  between  simple 
bitters  and  true  stomachic  drugs.  The  former  stimulate  the 
appetite,  while  the  latter  (the  complex  bitters)  stimulate  not 
only  the  appetite,  but  the  secretory  and  motor  functions  of 
the  stomach  as  well.  How  the  stimulating  effect  upon  the 
appetite  and  digestive  functions  is  brought  about  is  not 
definiteh^  known.  These  remedies  are  indicated,  as  a  rule, 
when  the  appetite  is  poor.  Loss  of  appetite  usually  accom- 
panies those  gastric  conditions  in  which  the  secretion  of 
gastric  juice  is  more  or  less  reduced.  According  to  the 
experiments  of  Boki  on  dogs,  quassia  and  calumba  increase 
the  secretion  of  gastric  juice  b^'  direct  effect  exerted  upon 
the  excised  mucous  membrane  of  the  stomach.  Reichmann 
was  among  the  first  to  investigate  the  action  of  vegetable 
bitters  on  man;  he  experimented  "udth  diseases  of  the  gastro- 
intestinal tract,  using  two  groups  of  bitter  remedies — pure 
bitters  and  the  aromatic  bitters.  The  introduction  of  a 
bitter  infusion  into  the  empty  stomach,  in  these  experi- 
ments, was  immediately  followed  hy  much  less  stimulation 
to  the  secretory  function  of  the  stomach  than  was  caused  by 
the  introduction  of  the  same  quantity  of  distilled  water.  As 
soon,  however,  as  the  bitter  infusion  left  the  stomach,  there 
was  a  marked  increase  in  gastric  secretion.  The  administra- 
tion of  a  bitter  with  the  food  was  followed  by  a  retardation 
of  gastric  digestion.  When  gastric  secretion  is  normal  the 
value  of  the  bitters  is  questionable. 

Alcohol  is  said  to  act  as  a  stimulant  to  gastric  secretion, 
but  it  has  no  effect  whatever  in  the  production  of  pepsin. 
When  alcohol  is  introduced  by  the  rectum  as  an  ingredient 
of  a  rectal  enema  it  has  the  power  of  stiniuhiting  gastric 


STRYCHNINE  AND  THE  BITTERS  1S9 

secretion.  The  bitter  tonics  have  been  given  as  tinctures, 
and  it  may  be  that  the  alcohol  in  the  tincture  stimulated  the 
secretion  of  gastric  juice  instead  of  the  bitters  themselves. 
According  to  the  investigations  of  Pawlow,  meat  juices, 
raw  meat,  meat  broth,  meat  extractives,  peptones,  milk, 
and  gelatin,  as  well  as  large  quantities  of  water,  have  the 
effect  of  stimulating  gastric  secretion. 

The  results  of  several  investigators  show  such  contra- 
dictions that  we  are  still  in  doubt  as  to  the  efficacy  of  the 
bitters.  According  to  Pawlow,  who  has  done  much  scientific 
work  in  investigating  the  physiologic  effect  of  bitters,  their 
action  does  not  consist  in  a  simple  physiologic  reflex,  but 
rather  in  a  certain  psychic  effect,  which  excites  secondarily 
the  secretory  function.  Pawlow  concludes  that  the  bitters 
act  on  the  gustatory  nerves  of  the  oral  cavity,  calling  forth 
a  desire  for  food. 

The  results  of  Reichmann's  experiments  have  led  him 
to  declare  that  bitter  remedies  should  be  administered  only 
in  those  cases  in  which  the  secretory  powers  of  the  stomach 
are  reduced,  when  they  should  be  administered  about  half  an 
hour  before  eating.  Other  investigators,  notably  Fawitzki, 
agree  with  Reichmann  in  regard  to  both  the  method  and  the 
time  of  administering  the  so-called  bitters  and  stomachics. 

Condurango  bark  was  declared  at  one  time  to  possess 
peculiar  efficacy  in  the  treatment  of  gastric  carcinoma. 
Since  1874,  when  Friedrich  first  called  attention  to  condu- 
rango as  a  therapeutic  agent  in  cancer  of  the  stomach,  it 
has  been  widely  administered,  but  not  with  the  results 
claimed  by  Friedrich.  While  this  drug  has  no  specific 
action  on  cancer,  it  is  of  some  value  as  a  stomachic.  Con- 
durango is  best  administered  in  the  form  of  a  decoction. 

I^ — Cort.  condurango 15  parts 

Macerate  for  twelve  hours  with  distilled  water      .      .  360  parts 

Then  evaporate  down  until,  when  strained,  it  equals  180  parts 

Sig. — A  tablespoonful  twice  daily. 

Orexin  (phenyldihydrochinazolin  hydrochloride)  was  intro- 
duced to  the  profession  in  1890  by  Penzoldt,  who  claimed 
that  it  possessed  the  property  of  inducing  hunger  and  im- 


190  MEDICATIONS 

proving  the  appetite.  Penzoldt's  claims  were  studied  by  a 
number  of  investigators,  who  for  the  most  part  found  orexin 
to  be  an  irritant  to  the  gastric  mucous  membrane.  The 
drug,  however,  appears  to  have  the  effect  of  increasing 
secretion  when  administered  in  subacidity.  For  the  original 
product  a  basic  orexin  was  later  substituted,  and  still  later 
the  tannate;  some  of  the  disagreeable  features  of  the  prepa- 
ration have  been  eliminated  by  administering  it  in  capsules. 
The  dose  should  be  followed  by  a  large  draught  of  water. 
According  to  Penzoldt,  the  best  results  are  obtained  from 
orexin  when  it  is  administered  in  a  dose  of  0.3  Gm.  (5  grains) 
once  a  day,  preferably  at  ten  o'clock  in  the  morning,  and 
continued  for  about  five  days.  The  special  indications  for 
its  administration  are  gastric  atony  and  acute  gastritis.  It  is 
contraindicated  in  such  conditions  as  gastric  ulcer,  hj^Der- 
acidity,  hypersecretion,  and  other  irritable  conditions  of  the 
stomach. 

Silver  Nitrate. — Silver  nitrate  is  prepared  by  the  interaction  of 
silver  and  nitric  acid ;  it  occurs  as  colorless  tabular  rhombic 
prisms.  It  is  soluble  in  half  its  weight  of  water.  Owing  to 
the  readiness  with  which  this  salt  combines  with  chlorides, 
all  solutions  should  be  made  with  distilled  water,  and  when 
they  are  to  be  preserved  for  any  length  of  time  they 
should  be  kept  in  amber-colored  containers.  Silver  nitrate 
is  shghtly  soluble  in  90-per-cent.  alcohol.  The  incompatibles 
of  this  salt  are  alkahes  and  the  carbonates,  chlorides,  acids 
(except  nitric  and  acetic),  potassium  iodide,  solutions  of 
arsenic,  and  astringent  infusions.  In  the  stomach  nitrate 
of  silver  is  decomposed  by  hydrochloric  acid  and  mucus, 
and  cannot  act  as  an  irritant  upon  the  mucous  membrane 
unless  administered  in  toxic  doses.  Baibakoff'  found  that 
silver  nitrate  has  the  property  of  increasing  the  acidity 
of  the  gastric  juice,  especially  in  cases  in  which  there  was 
hyperacidity  before  the  use  of  the  drug.  According  to 
this,  silver  nitrate  is  contraindicated  in  hyperacidity,  hyper- 
secretion, and  peptic  ulcer.  The  silver  salts  are  indicated 
rather  in  the  treatment  of  the   subacid  conditions  which 

'  Roussky  \'ratch,  August  20,  1905. 


GASTRIC  SEDATIVES  191 

usually  accompany  chronic  gastric  catarrh.  In  chronic  gas- 
tritis the  power  to  digest  proteins  is  somewhat  diminished, 
so  the  effect  of  the  silver  salts  by  way  of  increasing  gastric 
secretion  meets  the  therapeutic  requirements  in  this  class  of 
cases.  Silver  nitrate  has  been  found  to  have  an  anticatarrhal 
action  on  the  gastric  mucosa  in  gastritis.  The  drug  exerts  an 
antifermentative  influence  also,  inhibiting  the  development 
of  gases,  belching,  and  eructations.  Experiments  have  shown 
that  silver  nitrate  possesses  the  power  of  increasing  gastric 
motility.  The  test  breakfast  has  been  found  to  leave  the 
stomach  within  a  shorter  interval  when  nitrate  of  silver  has 
been  administered  than  when  no  medication  is  employed. 

The  dosage  of  nitrate  of  silver  should  be  so  regulated  as 
to  meet  the  requirements  of  the  individual  case  or  particular 
stage  in  the  progress  of  the  disease.  Large  doses  (0.03  Gm. 
— 4-  grain)  administered  three  times  a  day  increase  the 
flow  of  gastric  juice;  usually,  how^ever,  this  effect  may  be 
accomplished  with  doses  as  small  as  0.002  Gm.  (gV  grain) 
given  three  times  a  day.  The  physician  administering 
nitrate  of  silver  should  be  on  his  guard  against  argjTia. 

Gastric  Sedatives. — Among  gastric  sedatives  are  drugs 
which  reduce  the  excitability  of  the  vomiting  centre.  In 
this  class  are  amyl  nitrite,  nitroglycerin,  opium,  chloral 
hydrate,  the  bromides,  and  dilute  hydrocyanic  acid.  As 
sedatives  to  the  afferent  nerves  of  the  stomach  may  be 
mentioned  hot  water,  ice,  dilute  hydrochloric  acid,  effer- 
vescing carbon  dioxide,  bismuth,  dilute  alkalies,  opium, 
ipecac,  and  calomel  in  small  doses. 

Amyl  Nitrite. — Amyl  nitrite  occurs  in  the  liquid  form, 
being  chiefly  an  isoamyl  nitrite.  It  is  an  ethereal  liquid  of 
a  yellowish  color,  fragrant  odor,  and  faintly  acid  reaction, 
readily  soluble  in  90-per-cent.  alcohol,  but  almost  insoluble 
in  water.  It  is  administered  as  a  vasomotor  dilator  in  cir- 
culatory disturbances,  in  the  form  of  vapor  (inhalation) 
from  an  amyl  nitrite  pearl,  or  thin  glass  shell,  which  is 
crushed  by  the  patient  in  a  handkerchief.  The  dose  in- 
ternally as  a  gastric  sedative  is  one-half  to  one  minim  in 
rectified  spirit. 


192  MEDICATIONS 

Nitroglycerin.  —  Nitroglycerin,  trinitrin,  or  glonoin,  is  a 
colorless  oily  liquid  with  a  sweetish  taste,  very  slight Ij^ 
soluble  in  water,  but  freely  soluble  in  fats,  oil,  alcohol,  or 
ether.  Its  uses  are  similar  to  those  of  amyl  nitrite.  The 
dose  is  one-half  minim  to  two  minims. 

Chloral  Hydrate. — Chloral  hydrate  is  prepared  from 
chloral  by  the  addition  of  water.  The  drug  occurs  in  colorless 
crystals,  soluble  in  an  equal  quantity  of  distilled  water, 
90-per-cent.  alcohol,  or  ether.  It  is  likewise  soluble  in 
four  parts  of  chloroform.  The  dose  is  0.3  to  1.2  Gm, 
(5  to  20  grains)  in  solution.  While  the  chief  use  of  chloral 
hydrate  is  as  a  hypnotic,  it  has  been  found  valuable  for 
allaying  vomiting  or  irritability  of  the  stomach,  owing  to 
the  sedative  action  exerted  on  the  vomiting  centre. 

Bromides. — The  bromides  are  gastric  sedatives,  inasmuch 
as  they  act  as  depressants  not  only  on  the  brain  and  spinal 
cord  but  on  the  peripheral  nerves. 

Dilute  Hydrocyanic  Acid. — Dilute  hydrocyanic  acid  is  an 
aqueous  solution,  a  colorless  liquid,  faintly  acid  in  reaction, 
with  a  specific  gravity  of  0.997.  It  is  incompatible  with 
the  salts  of  iron,  copper,  and  silver.  It  produces  a  peculiar 
sensation  in  the  mouth  and  throat  when  taken  internally; 
its  chief  use  is  as  a  sedative  to  the  nerves  of  the  stomach. 
It  is  employed  to  relieve  gastric  pain  and  allay  vomiting  in 
ulcer,  and  in  reflex  and  other  nervous  disorders  of  the 
stomach.  In  all  probability  the  greater  share  of  the  influ- 
ence exerted  by  this  drug  on  the  conditions  named  is  ex- 
erted by  way  of  the  medulla  oblongata.  Hydrocyanic  acid 
is  speedily  disseminated  throughout  the  tissues,  selecting  for 
its  action  the  nerve  structures.  The  drug  also  acts  as  a 
cardiac  sedative,  especially  in  heart  conditions  resulting 
from  derangement  of  the  gastric  function.  The  dose  of  the 
dilute  acid  is  0.1  to  0.3  Cc.  (2  to  5  minims). 

Cannabis  Indica.  —  Cannabis  indica  (Indian  hemp)  is 
prepared  from  the  dry  tops  of  Cannabis  sativa,  grown 
in  India.  Among  the  preparations  prescribed  are  the 
alcoholic  extract,  dose  0.015  to  0.06  Gm.  ([  to  1  grain) 
in  pill  form,  and  tincture  of  cannabis  indica,  dose  0.3  to 


GASTRIC  ANODYNES  193 

1  Cc.  (5  to  15  minims).  The  drug  may  be  used  internally 
as  a  corrective  of  griping  purgatives  such  as  podophyllin 
and  colocynth.  Large  doses  produce  a  peculiar  species  of 
intoxication,  involving  disordered  consciousness  of  person- 
ality, locality,  and  time.  The  local  effect  upon  the  stomach 
is  that  of  a  sedative.  The  drug  is  said  to  provoke  a 
ravenous  appetite  at  times. 

Cocaine  Hydrochloride. — Cocaine  hydrochloride,  the  salt  of 
cocaine  most  frequently  employed  for  medicinal  purposes, 
is  obtained  from  the  leaves  of  the  Erythroxylon  coca.  The 
salt  consists  of  fine  crystals  that  are  soluble  in  half  their 
weight  of  cold  water  and  in  four  parts  of  alcohol.  With 
water,  cocaine  hydrochloride  forms  a  colorless  solution, 
neutral  in  reaction;  the  solution  has  a  bitter  taste,  causing 
tingling  of  the  tongue,  soon  followed  by  numbness.  The 
dose  is  0.01  to  0.03  Gm.  (i  to  h  grain).  Cocaine  hydro- 
chloride as  a  local  anesthetic  is  well  known.  The  effect  of 
the  drug  is  confined  to  mucous  membrane  and  the  deeper 
tissue;  the  skin  is  peculiarly  exempt.  Cocaine  hydrochloride 
may  be  used  as  a  local  sedative  in  all  irritations  of  the 
stomach.  In  vomiting  accompanied  by  pain  it  has  been 
found  extremely  valuable. 

Gastric  Anodynes. — Chloroform. — Five  to  six  drops  of  chloro- 
form on  sugar  or  ice  is  useful  in  the  treatment  of  selected 
cases  of  gastralgia.  Chloroform  has  been  found  not  only 
to  afford  temporary  relief  from  pain,  but  to  arrest  the  course 
of  the  general  disease.  Chloroform  water,  1  to  150,  can  be 
administered  every  hour  in  tablespoonful  doses.  Its  action 
is  that  of  a  local  sedative  and  antiseptic.  Small  doses  of 
chloroform  have  been  found  capable  of  arresting  vomiting 
in  gastric  ulcer.  Chloroform  may  be  administered  con- 
veniently with  bismuth. 

Orthoform. — Orthoform  is  a  methylaminoparaoxybenzoate. 
It  occurs  in  fine,  whitish,  odorless,  tasteless  powder,  sparingly 
soluble  in  water,  and  is  credited  with  possessing  local  anes- 
thetic and  antiseptic  properties.  It  is  said  to  be  non-toxic. 
Its  analgesic  action  is  manifest  only  when  the  drug  comes 
into  direct  contact  with  the  exposed  ends  of  nerves.    Ortho- 

13 


194  MEDICATIONS 

form  as  a  local  anesthetic  resembles  cocaine  somewhat,  but 
differs  from  the  latter  in  the  fact  that,  owing  to  its  insolu- 
bility, it  does  not  penetrate  the  tissues.  It  has  been  pre- 
scribed extensively,  to  be  taken  by  the  mouth,  for  the  relief 
of  the  pain  of  gastric  ulcer ;  and  the  fact  that  it  does  not  get 
below  the  surface,  and  therefore  cannot  relieve  any  but 
superficial  pain,  makes  it  useful  as  a  diagnostic  agent.  When 
relief  of  gastric  pain  follows  its  internal  administration,  this 
fact  is  considered  an  indication  of  the  presence  of  ulcer  of 
the  stomach.  The  internal  dose  is  0.5  to  1  Gm.  (7  to  15 
grains)  in  the  form  of  a  mixture. 

Murdoch^  reports  a  number  of  instances  where  orthoform 
was  used  for  the  relief  of  pain  in  suspected  ulcer  of  the 
stomach.  In  one  case  in  particular  the  relief  was  so  pro- 
nounced as  to  leave  no  doubt  of  the  presence  of  ulcer,  a 
condition  which  in  spite  of  rest  in  bed  and  liquid  food  for 
nearly  two  months  had  showed  no  inclination  to  heal.  In 
this  case  not  only  did  the  painful  symptoms  disappear  on 
the  administration  of  orthoform,  but  the  patient  made  a 
complete  recovery.  The  same  writer  mentions  cases  in 
which  the  diagnosis  of  appendicitis,  biliary  cohc  and  gas- 
tritis had  been  made,  and  the  correct  diagnosis  was  estab- 
lished only  after  the  administration  of  orthoform.  The 
diagnostic  value  of  orthoform  in  gastric  ulcer  depends  upon 
the  fact  that  the  drug  will  not  anesthetize  nerve  endings 
when  they  are  covered  by  skin  or  mucous  membrane.  If  it 
relieves  pain  in  the  stomach,  it  can  do  so  only  by  coming  in 
contact  with  surface  denuded  of  mucous  membrane,  as  in 
the  case  of  gastric  ulcer. 

Anesthesin. — Anesthesin  is  ethyl  paraminobenzoate,  or  the 
ethyl  ester  of  paraminobenzoic  acid.  It  occurs  as  a  white, 
crystalhne,  odorless,  and  tasteless  powder,  which  produces  a 
sensation  of  numbness  when  placed  on  the  tongue.  It  is 
with  difficulty  soluble  in  hot  water,  and  almost  insoluble 
in  cold.  In  six  parts  of  alcohol  or  ether  it  should  form  a 
clear,  colorless,  neutral  solution.  It  may  be  sterilized  in  oil 
solutions  without  undergoing   decomposition.     Anesthesin 

»  Medical  News,  October  8,  1904. 


DRUGS   USED  INCIDENTALLY  IN  GASTRIC  DISORDERS     195 

was  introduced  to  the  profession  as  a  local  anesthetic 
resembling  orthoform  in  its  action.  It  does  not  penetrate 
mucous  membranes,  and,  being  insoluble  in  water,  cannot 
be  administered  hypodermically.  It  has  been  prescribed 
for  the  relief  of  pain  in  gastric  ulcer  and  gastric  cancer 
and  in  various  forms  of  gastralgia.  The  dose  is  0.3  to 
0.5  Gm.  (5  to  7  grains)  in  capsule.  The  drug  causes  good 
local  anesthesia  without  irritation  when  applied  to  raw  or 
ulcerated  surfaces.  Anesthesin  is  practically  non-toxic. 
Taussig  reports  that  huge  doses  are  necessary  to  produce 
even  temporary  ailments  in  rabbits,  and  no  untoward  effects 
have  been  observed  in  man. 

Cykloform. — Cykloform^  is  a  local  anesthetic.  It  has  the 
peculiarity  that  it  is  soluble  with  difficulty  in  water,  easily 
soluble  in  alcohol  and  ether,  but  insoluble  in  chloroform. 
On  account  of  the  insolubility  of  cykloform  in  aqueous 
liquids,  its  local  anesthetic  effect  endures  longer  than  that  of 
cocaine  or  novocaine,  and  its  systemic  effects  by  absorption 
are  much  less.  It  has  been  used  with  success  in  gastralgia  in 
the  dose  of  0.2  to  0.5  Gm.  (3  to  7  grains).  In  the  pains 
of  intestinal  tuberculosis  with  diarrhea  it  has  been  found 
valuable,  relief  being  afforded  sometimes  in  fifteen  minutes, 
often  within  two  or  three  hours.  In  the  vomiting  of  preg- 
nancy it  is  used  in  doses  of  0.2  to  0.4  Gm.  (3  to  6  grains). 

Drugs  Used  Incidentally  in  Gastric  Disorders. — We  have  a 
number  of  drugs  which  are  used  largely  for  their  indirect 
effect  in  the  treatment  of  gastric  conditions.  Atropine,  the 
alkaloid  of  belladonna  leaves  or  root,  performs  an  important 
role  when  there  is  an  excess  of  secretion.  Belladonna  pro- 
duces a  slightly  anodyne  effect  when  taken  into  the 
stomach,  and  has  been  used  to  relieve  some  forms  of  gas- 
tralgia. The  hypodermic  use  of  atropine  in  hyperacid  con- 
ditions was  first  recommended  by  Riegel.  Owing  to  the 
fact  that  in  order  to  obtain  inhibition  of  gastric  secretion 
the  dose  of  the  drug  must  be  somewhat  large,  there  is  more 

'  Wyss,  Ueber  die  Wirksamkeit  cles  C3"kloform  als  Anesthetikum  bei  Affek- 
tionen  des  Magen-Darmtraktes,  Archiv  fiir  Verdauungskrankheiten,  October 
10,  1910. 


196  MEDICATIONS 

or  less  danger  of  poisoning  from  the  use  of  it.  Regarding 
the  action  of  atropine,  pilocarpine,  and  nicotine,  it  may  be 
said  that  atropine  in  small  doses  injected  directly  into  the 
blood  or  into  the  salivary  gland  duct  prevents  the  action  of 
the  chorda  tympani,  thus  producing  inhibition  of  the  sali- 
vary secretion;  it  apparently  paralyzes  the  endings  of  the 
cerebral  fibres  in  the  glands.  Pilocarpine  is  mentioned, 
owing  to  the  fact  that  its  effect  upon  the  secretory  mech- 
anism is  exactly  opposite  to  that  of  atropine.  From  the 
minutest  doses  of  pilocarpine  we  get  a  continuous  secretion 
of  saliva;  it  is  supposed  that  the  drug  stimulates  the  endings 
of  the  secretory  fibres  of  the  salivary  glands.  Pilocarpine  and 
atropine  are  to  a  certain  extent  physiologic  antagonists. 
Nicotine  in  its  effect  upon  salivary  secretion  differs  from 
either  of  the  other  two ;  it  inhibits  the  action  of  the  secre- 
tory nerves  by  paralyzing  the  connections  between  the  nerve 
fibres  and  the  ganglion  cells. 

Schick  and  Tabora^  report  prompt  healing  in  some  rather 
obstinate  cases  of  ulcer  of  the  stomach  when  the  patients 
were  placed  upon  a  systematic  course  of  atropine.  The 
drug  no  doubt  soothed  and  relaxed  the  musculature  of  the 
pylorus,  at  the  same  time  exercising  an  inhibitory  effect 
upon  the  gastric  secretion.  Schick  recommends  that  atro- 
pine sulphate  be  administered  morning  and  evening  for 
four  to  six  weeks,  in  the  dosage  of  0,001  to  0.0015  Gm. 
(liV  to  4V  grain)  hypodermically.  According  to  this  writer, 
subsidence  of  the  subjective  symptoms  usually  followed 
the  administration  of  the  drug. ,  Atropine  has  been  found 
useful  also  in  the  treatment  of  spastic  constipation,  spas- 
modic asthma,  pylorospasm,  lead  colic,  and  cardiospasm. 

Eumydrin. — Eumj^drin  (atropinemethyl  nitrate)  is  the 
nitrate  of  methylated  atrojjine.  It  is  simila]'  in  its  action  to 
atropine,  but  reputedly  much  less  toxic,  and  may  therefore 
be  given  in  larger  doses.  The  dose  internally  is  0.001  to 
0.0025  Gm.  {i^^  to  t,V  grain).  According  to  Schoenheim, 
of  Buda]:)est,  eumydrin  is  fifty  times  less  poisonous  than 
atropine  sulphate,  and,  owing  to  the  introduction  of  the 

'  Wiener  klinisohc  Wochenschrift,  Vienna,  August  2r\  1910. 


ANTISEPTICS  197 

methyl  p'oup,  is  entirely  devoid  of  any  action  upon  the 
central  nervous  system.  It  is  therefore  able  to  act  more 
powerfully  upon  the  peripheral  nerve  endings  and  secre- 
tory glands.  The  influence  of  eumydrin  upon  gastric  and 
intestinal  affections  was  first  investigated  by  Haas,i  who 
reports  satisfactory  results  from  the  use  of  the  drug  in  the 
treatment  of  functional  secretory  disturbances  as  well  as 
gastric  neuroses.  Schoenheim  and  Hirchler  have  also  noted 
satisfactory  results  in  gastric  ulcer  as  well  as  in  nervous 
dyspepsia  and  hyperchlorhydria ;  there  was  not  only  a 
complete  subsidence  of  the  marked  gastralgia,  but  in  the 
majority  of  cases  a  diminution  of  hydrochloric  acid  secretion 
occurred.  Massini^  looks  favorably  upon  the  introduction 
of  eumydrin  as  a  substitute  for  atropine,  inasmuch  as  the 
latter  has  produced  general  disturbances  and  intoxication. 
The  dose  of  eumydrin  is  0.001  to  0.003  Gm.  (^V  to  ^V 
grain) . 

Antiseptics. — Among  the  drugs  used  as  antiseptics  for  the 
stomach  we  have  resorcinol,  phenol,  and  the  salicylates. 

Resorcinol. — Resorcinol  is  a  phenol  derivative  which  occurs 
in  white  lustrous  crystals  with  a  sweetish  pungent  taste. 
It  is  soluble  in  equal  parts  of  water,  twent}^  parts  of  olive 
oil,  or  half  its  weight  of  alcohol.  Resorcinol  is  essentially 
an  antiseptic,  disinfectant,  analgesic,  and  hemostatic,  being 
non-irritating  in  solutions  of  2  to  10  per  cent.  During  the 
last  few  years  it  has  been  used  in  the  treatment  of  gastric 
ulcer  in  doses  of  0.12  to  0.25  Gm.  (2  to  4  grains)  before 
meals,  in  pill  or  capsule.  Ewald  particularly  recommends 
it  as  an  antiferment  when  the  patient  is  troubled  with  gas 
formation  in  the  stomach. 

Phenol.  —  Phenol,  or  carbolic  acid,  is  obtained  by  the 
fractional  distillation  of  coal  tar.  It  occurs  in  colorless 
hygroscopic  crystals,  soluble  in  12  parts  water,  freely  soluble 
in  glycerin.  Phenol  is  an  excellent  antizymotic.  The  man- 
ner in  which  it  performs  the  function  of  antizymosis  is  not 
well  understood.    In  vomiting  due  to  a  neurosis  or  gastric 

1  Therapie  der  Gegenwart,  March,  1905. 

2  Gazzetta  degli  Ospitali. 


198  MEDICATIONS 

irritation  0.03  to  0.12  Cc.  (2  to  2  minims)  depresses  the 
sensory  nerves  of  the  stomach.  Phenol  is  valuable  in  cases 
of  gastric  fermentation. 

Salicylates. — Writing  on  the  subject  of  the  employment 
of  salicylates  in  dyspeptic  conditions,  Pascault^  maintains 
that  the  salicylates  are  sedative  in  their  action.  Applied 
to  a  fresh  wound,  he  says,  sodium  salicylate  sufficiently 
diluted  will  mitigate  pain,  reduce  congestion,  and  arrest 
hemorrhage.  As  antizymotics,  the  salicylates,  particularly 
sodium  salicylate,  retard  the  fermentation  of  milk  in  the 
stomach  and  promote  its  digestion.  Given  to  dyspeptics 
they  destroy  the  fetid  odor  of  the  breath  as  well  as  of  the 
feces.  Pascault,  referring  to  the  influence  of  the  salicylates 
upon  hyperesthesia,  favors  the  use  of  sodium  salicylate. 
The  drug  should,  as  a  rule,  follow  the  administration  of  a 
purgative  in  order  that  the  colon  may  be  kept  free,  inasmuch 
as  gastric  disturbances  are  often  caused  by  fecal  impaction. 
Pascault  reports  that  in  his  hands  the  results  of  the  adminis- 
tration of  the  salicylates  have  ranged  from  negative,  in  a 
few  nervous  persons  whose  gastric  troubles  were  cerebral 
rather  than  gastric,  to  positive  and  lasting  in  the  majority 
of  other  patients.  This  writer  advocates  the  use  of  the 
salicylates  for  controlling  certain  reflex  symptoms  of  gastric 
origin,  such  as  flushing  of  the  face,  congestive  headache, 
vertigo,  and  insomnia  of  gastric  origin. 

Iodine. — Tincture  of  iodine  is  occasionally  employed  in 
the  treatment  of  gastric  ulcer,  both  for  its  anodyne  effect 
and  as  a  stimulus  to  healing.  It  is  likewise  a  valuable  anti- 
septic. Administered  in  drop  doses,  it  has  proved  efficacious 
in  vomiting  of  pregnancy  that  has  failed  to  yield  to  other 
measures. 

Hydrogen  Peroxide. — Hydrogen  peroxide  is  prepared  by 
the  interaction  of  water,  barium  peroxide,  and  a  dilute 
mineral  acid,  at  a  temperature  below  50°  F.  It  is  a 
colorless,  odorless  liquid  with  a  slightly  acrid  taste.  Heat 
decomposes  it  into  water  and  oxj^gen.  Aqua  hydrogenii 
dioxidi  U.S. P.  should  contain  3  per  cent,  of  absolute  hydro- 

»  Bulletin  G('n<'Tal  tic  Th<''niiK'utic|iic,  July  HO,  I'.tOT. 


EMOLLIENTS  199 

gen  dioxide.  It  is  a  powerful  oxidizing  agent,  possessing 
marked  disinfectant  properties.  Rinsing  the  mouth  with  a 
1-per-cent.  solution  of  hydrogen  peroxide  has  been  found  to 
cause  marked  increase  in  the  secretion  of  saliva.  Internally 
administered,  hydrogen  peroxide  has  been  found  to  reduce 
the  total  acidity  of  the  secretion,  especially  the  proportion 
of  free  hydrochloric  acid.  When  the  purpose  is  to  reduce 
the  acidity  within  normal  bounds,  Petri^  advises  giving  the 
dioxide  like  a  mineral  water  on  the  fasting  stomach  m  the 
morning.  It  should  be  given  in  the  proportion  of  1  to  3 
Cc.  in  200  to  300  Cc.  of  water.  In  hyperacidity  and  acid 
fermentation  hydrogen  peroxide  may  be  used  in  0.25  to  0.5 
per  cent,  solution  for  washing  out  the  stomach.  The  drug 
is  useful  in  the  treatment  of  hyperacidity,  hyperchlorhydria, 
ulcer,  and  spasm  of  the  pylorus. 

Emollients. — Olive  Oil. — Cohnheim  was  among  the  first  to 
draw  attention  to  the  value  of  oil  in  {he  treatment  of  gastric 
affections.  He  mentions  a  case  of  probable  traumatic  ulcer 
of  the  stomach  so  painful  that  the  patient  avoided  food,  in 
which  complete  relief  of  the  distressing  symptoms  followed 
the  administration  of  a  wineglass  of  olive  oil  before  meals. 
Amelioration  of  symptoms  from  the  use  of  olive  oil  has 
been  reported  even  in  cancer  of  the  stomach.  Satisfactory 
results  have  likewise  been  reported  in  the  treatment  of 
pyloric  stenosis.  Cowie^  and  Munson  sum  up  the  results 
of  their  investigation  of  the  effects  of  oil  upon  gastric  acidity 
and  gastric  motility  as  follows : 

1.  Olive  oil  and  cottonseed  oil,  when  given  in  connection 
with  the  usual  test  breakfast,  decrease  the  gastric  acidity 
at  the  end  of  the  hour  and  retard  the  evacuation  of  the 
stomach. 

2.  The  beginning  of  the  secretion  of  hydrochloric  acid 
is  delayed  when  oil  precedes  the  meal,  unchanged  when  oil 
follows  the  meal. 

3.  The  height  of  digestion  is  delayed  when  oil  is  given 
either  before  or  after  the  meal. 

^  ArcMv  fiir  Verdauungskrankheiten,  October  15,  1908,  p.  479. 
■^  Archives  of  Internal  Medicine,  January,  1908. 


200  MEDICATIONS 

4.  The  height  of  secretion  is  lowered  when  oil  precedes 
the  meal,  unchanged  when  oil  follows  the  meal. 

5.  If  the  progress  of  digestion  be  watched  by  the  removal 
of  small  samples  of  stomach  fluid  at  frequent  intervals, 
it  will  be  observed,  when  oil  precedes  the  meal  bj^  one-half 
hour,  that  at  the  end  of  what  is  usually  taken  as  the  digestive 
period  for  a  test  breakfast  (three-fourths  to  one  hour)  the 
acidity  is  distinctly  lower,  while  as  great  a  height  as  that 
attending  the  digestion  of  the  control  meal  is  frequently 
reached  some  minutes  later. 

6.  The  action  of  oil  on  the  stomach  functions  is  only  a 
temporary  one.  It  has  no  effect  on  subsequent  meals 
unaccompanied  by  oil. 

7.  The  therapeutic  value  of  oil  is  apparent.  In  suitable 
cases  it  is  preferable  to  antacids  because  of  its  calorific  value. 
In  hyperchlorhydria  it  should  follow  the  meal.  In  stasis 
and  in  persistent  slow  evacuation  it  should  be  eschewed. 
In  hypermotility  it  may  be  given  before,  during,  or  after 
the  meal. 

8.  Oil  lowers  the  gastric  secretion  both  by  reflex  central 
inhibitory  stimulation  and  by  mechanical  inhibition  of  food 
stimulation — (a)  by  coating  the  food;  (b)  by  coating  the 
stomach  wall. 

Cohnheim  reports  satisfactory  results  from  the  use  of  oil 
in  the  treatment  of  spasm,  pain,  and  hyperacidity,  as  well  as 
for  increa'sing  the  nutrition  of  the  body.  Permanent  cures 
have  been  reported  in  cases  of  spastic  stenosis,  fissures  and 
erosions  of  the  pylorus,  ulcer,  and  gastritis. 

Olive  oil  is  laxative  and  nutritious.  During  its  use  patients 
may  pass  lumps  of  white  fat  composed  of  undigested  pal- 
mitin.  In  doses  of  one-half  to  three  ounces  it  has  been 
known  to  relieve  obstructive  jaundice.  It  is  a  valuable 
remedy  in  hepatic  colic.  In  gallstone  disease  lai-ge  doses, 
from  three  to  five  ounces,  of  olive  oil  will  frequent  I3'  miti- 
gate pain,  though  not,  as  supposed  by  some,  bring  about  a 
disintegration  of  gallstones. 

Epinephrin. — Epincphrin  is  a  substance  obtained  from 
the  su])rarenal   glands  of   sheep   or   other   animals.     It  is 


EMOLLIENTS  201 

an  alkaloidal  product,  slightly  alkaline  in  reaction.  The 
action  of  epinephrin  is  probably  a  stimulation  of  the 
sympathetic  nerve  endings.  It  is  a  powerful  styptic,  exer- 
cising a  constricting  effect  on  the  bloodvessels,  with  a  con- 
sequent raising  of  blood  pressure.  The  dose  of  a  1-to-lOOO 
solution  is  0.3  to  2  Cc.  (5  to  30  minims)  every  two  or  three 
hours.  Hypodermically  the  dose  is  0.06  to  1  Cc.  (1  to  15 
minims)  of  a  1-to-lOOO  solution  diluted  with  sterile  water. 
There  are  analogous  preparations  put  upon  the  market  by 
various  pharmaceutical  houses,  under  such  names  as  adren- 
alin, adnephrin,  adrin,  suprarenahn,  etc.  AdrenaUn  has 
been  emploj'ed  to  arrest  gastric  hemorrhage  in  doses  of  20 
to  30  drops  of  a  1-to-lOOO  solution  three  to  four  times  a  day. 
Many  investigators  report  no  untoward  sequelae  even  when 
the  administration  of  the  drug  was  prolonged  over  several 
weeks. 


CHAPTER    IX 

INDICATIONS   FOR   SURGICAL   INTERVENTION 

A  NEW  epoch  in  gastric  surgery  opened  with  Billroth's 
first  successful  resection  of  the  stomach  for  cancer  of  the 
pylorus  on  February  28,  1881,  and  with  the  introduction  of 
Wolfler's  gastroenterostomy  on  September  27,  1881.  Since 
then  the  results  have  been  more  favorable,  owing  both 
to  the  better  technique  and  to  experience  derived  from 
success  and  failure.  Important  in  this  regard  is  also  the 
fact  that,  owing  to  the  more  extensive  employment  of  the 
stomach  tube,  the  diagnosis  of  gastric  disorders  has  become 
more  accurate.  We  should  not  be  misled  by  statistics  on 
surgery  of  the  stomach,  inasmuch  as  the  operative  results 
of  twenty  years  ago  cannot  be  compared  with  those  of  the 
last  few  years.  The  results  of  gastroenterostomy  following 
a  benign  stenosis  of  the  pylorus  have  been  so  favorable 
that  some  surgeons  are  led  to  believe  that  all  cases  of  indi- 
gestion which  have  resisted  medicinal  treatment  require 
an  exploratory  incision.  They  apparently  overlook  the  fact 
that  venous  congestion  of  the  gastric  mucosa  caused  by  a 
derangement  of  the  heart,  lung,  liver,  or  kidney  will  produce 
severe  digestive  symptoms,  and  that  an  exploratory  incision 
without  due  deliberation  may  do  more  harm  than  good. 

During  the  last  ten  years  the  operation  of  gastroenter- 
ostomy has  come  into  great  repute,  and  in  some  quarters 
the  opinion  seems  to  prevail  that  this  radical  operation  is 
a  panacea  for  each  and  every  form  of  indigestion.  That 
experience,  however,  has  not  warranted  this  extreme  view 
is  emphasized  by  Deaver,^  who,  while  insisting  that  gastro- 
enterostomy is,  when  indicated,  one  of  the  most  valuable 
of   surgical    procedures,    warns   against   its    indiscriminate 

'  American  .Journal  of  the  Medical  Sciences,  May,  lUlO. 


INDICATIONS  FOR  SURGICAL  INTERVENTION         203 

use,  especially  in  the  various  forms  of  gastric  neurosis. 
There  is  no  class  of  jialients  more  anxious  to  undergo  oper- 
ation than  the  neurotic,  especially  when  neurasthenia  has 
assumed  the  symptoms  of  indigestion  and  abdominal  pain 
or  discomfort.  There  are  many  sad  instances  of  men  and 
women  who  travel  from  one  gastric  surgeon  to  another 
asking  that  the  abdomen  be  opened  and  the  course  of  the 
alimentary  tract  so  changed  that  their  sufferings  may  be 
relieved.  In  such  cases  operation  is,  of  course,  to  be  con- 
demned, inasmuch  as  its  results,  as  Deaver  points  out,  are 
disastrous  to  the  patient.  Indiscriminate  operation  has 
done  more  harm  to  the  advancement  of  gastric  surgery  than 
can  be  well  realized.  It  is  the  internist  who  has  to  deal 
with  the  case  after  the  surgeon  has  discharged  the  patient 
as  cured.  Some  of  these  patients  are  sorry-looking  indi- 
viduals, and  yet  many  an  internist  acquiesces  without  a 
word  of  condemnation  of  this  sacrifice  to  experimentation. 
How  absurd  to  accept  unchallenged  the  assertion  that  most 
of  the  stomach  cases  coming  into  the  hands  of  the  internist 
are  cases  of  incipient  carcinoma  and  should  be  subjected 
to  an  exploratory  operation!  When  surgical  intervention  is 
truly  indicated  there  is  no  class  of  cases  in  which  success 
is  so  gratifying;  but,  taken  as  a  whole,  less  than  2  per 
cent,  of  stomach  cases  require  surgery.  The  most  frequent 
condition  demanding  surgery  is  obstruction  of  the  pylorus, 
in  which  condition  gastric  retention  is  extreme.  In  severe 
cases  food  is  found  in  the  morning  in  the  fasting  stomach, 
often  as  much  as  three  or  four  quarts,  some  of  which  was* 
taken  one  or  more  days  before.  The  stomach  endeavors  to 
compensate  for  the  pyloric  obstruction  by  increased  mus- 
cular effort.  This  brings  about  hypertrophy  of  the  organ, 
which  is  soon  followed  by  dilatation.  Dilatation  is  almost 
invariably  present  when  there  is  stenosis  of  the  pylorus. 

Before  operative  treatment  of  the  stomach  is  advised,  a 
number  of  factors  should  be  taken  into  consideration,  the 
most  important  of  which  are  the  general  condition  of  the 
patient  and  the  condition  of  the  vascular  system,  since  both 
indicate  his  power  of  resistance.     The  age  of  the  patient  is 


204         INDICATIONS  FOR  SURGICAL  INTERVENTION 

also  important.  Although  young  people  undergo  a  seri- 
ous surgical  operation  with  better  chances  of  recovery  than 
older  ones,  no  definite  lines  of  age  can  be  drawn.  In  cases 
complicated  with  diabetes,  Bright's  disease,  or  grave  cardiac 
affection,  operation  on  the  stomach  is,  as  a  rule,  contra- 
indicated. 

Indications  for  Gastrostomy. — The  simplest  operation  on  the 
stomach  is  gastrostomy.  It  is  indicated  in  impermeable 
strictures  of  the  esophagus,  for  the  removal  of  foreign  bodies 
situated  so  low  down  in  the  esophagus  as  to  make  their 
removal  from  above  impossible,  for  the  removal  of  foreign 
bodies  from  the  stomach,  and  for  the  purpose  of  feeding. 

In  carcinomatous  strictures  of  the  esophagus  or  of  the 
cardia,  gastrostomy  is  of  doubtful  value,  and  should  be 
undertaken  only  when  the  stenosed  part  is  impervious  even 
to  fluids.  In  such  cases  the  first  step  should  be  to  admin- 
ister small  doses  of  morphine  for  the  relief  of  pain  and  to 
replace  mouth  feeding  by  rectal  alimentation  for  several 
days,  as  it  is  not  an  uncommon  occurrence  under  this 
treatment  for  the  stenosed  passage  to  become  fairly  patulous. 
The  benefit  derived  from  gastrostomy  undertaken  for  the 
relief  of  carcinoma  is  very  hmited,  as  it  consists  only  in 
the  prolongation  of  a  wretched  existence  for  a  few  weeks 
or  months. 

Gastric  Ulcer. — A  simple  uncomplicated  gastric  ulcer  does 
not  demand  surgical  intervention.  Only  in  the  event  of 
complications,  or  of  the  ulcer  defying  thorough  internal 
treatment  and  impairing  nutrition  by  interference  with 
motihty,  should  there  be  any  thought  of  surgical  intervention. 
In  the  present  state  of  the  art  of  diagnosis  we  can  have 
only  a  suspicion  as  to  the  seat  of  the  ulcer.  We  know  that 
three-fifths  of  all  gastric  ulcers  are  situated  at  the  lesser 
curvature  on  the  posterior  wall  of  the  stomach,  a  surgically 
inaccessible  place.  Mayo^  reports  that  more  than  90  per 
cent,  of  all  gastric  ulcers  are  situated  along  the  lesser  curva- 
ture; and  that  those  not  so  situated  are  more  frequent  on 

'  Disorders  of  the  Stomach  and  Duodenum,  with  Sjjecial  Reference  to 
Ulcers,  Boston  Medical  and  Surgical  Journal,  April  0,  1911. 


IN  GASTRIC   ULCER  205 

the  posterior  than  on  the  anterior  wall  of  the  stomach. 
Unless,  therefore,  there  is  a  well-developed  ulcer  of  the 
pylorus  which  has  been  diagnosticated  by  the  fact  of  re- 
tention, it  is  impossible  to  make  a  safe  prognosis  of  recovery 
or  even  of  improvement  through  surgical  intervention.  In 
eases  diagnosticated  as  ulcer  of  the  stomach,  either  the  ulcer 
has  not  been  found  on  laparotomy,  or,  if  found,  adhesions 
or  an  unfavorable  position  have  rendered  operative  measures 
impracticable. 

William  J.  Mayo  says:  ''Nearly  all  the  failures  of  surgery 
for  ulcer  of  the  stomach  are  to  be  found  in  the  group  of 
so-called  clinical  or  medical  ulcers,  because  (a)  the  ulcer 
is  not  found,  and  many  times  its  existence  is  problematic; 
(6)  the  condition  is  often  confused  with  pyloric  spasm,  atonic 
dilatation,  gastroptosis,  gastric  neuroses,  or  other  morbid 
non-surgical  condition;  (c)  simple  ulcer  does  not  give  rise 
to  that  mechanical  interference  with  the  progress  of  food 
which  would  introduce  an  operative  indication." 

Munro,  in  a  paper  read  before  the  Congress  of  Physicians 
and  Surgeons  in  1907,  said,  referring  to  the  unsatisfactory 
results  from  gastroenterostomy  in  gastric  ulcer:  "It  is  wise 
to  close  the  abdomen  when  there  is  no  gross  ulcer,  no  actual 
pyloric  obstruction,  or  other  crippling  lesion."  He  had 
learned  from  observation  of  the  results  of  many  cases  that 
gastroenterostomy  under  such  conditions  was  useless. 

So  far  as  surgery  is  advisable,  no  procedure  but  the  removal 
of  the  ulcer  by  excision  or  gastroenterostomy  is  to  be  con- 
sidered. Such  operations  do  not  remove  the  cause  of  the 
ulcer  nor  its  tendency  to  new  formation,  nor  do  they  improve 
motility  or  reduce  hyperacidity;  they  do  remove  the  dangers, 
however,  accompanying  the  ulcer,  such  as  hemorrhage,  per- 
foration, and  malignant  degeneration.  Gastroenterostomy 
and  favorable  drainage  protect  the  ulcer  from  irritation  by 
the  hyperacid  gastric  contents,  and  some  ulcers  w^hich  have 
defied  every  kind  of  therapy  will  sometimes  heal  or  become 
latent  after  gastroenterostomy.  This  operation  is  frequently 
reported  to   have  given  successful   results  in  ulcer  of  the 


206         INDICATIONS  FOR  SURGICAL  INTERVENTION 

stomach  without  obstruction.  In  these  cases,  as  Murphy^ 
has  pointed  out,  the  operation  per  se  may  not  have  been 
the  positive  factor  in  the  favorable  results  obtained;  the 
operator,  either  intentionally  or  not,  may  have  folded  the 
ulcer  on  itself  or  ligated  the  vessels  supplying  it.  The  one 
definite  indication  for  a  gastroenterostomy  in  gastric  ulcer 
is  for  the  relief  of  obstruction  so  that  the  food  may  pass 
from  the  stomach  into  the  intestine. 

Ulcer  of  the  pylorus  or  duodenum  can  be  cured  by  gastro- 
enterostomy, but  this  operation  will  not  cure  ulcers  in  other 
parts  of  the  stomach. 

Deaver  and  Ashhurst^  say:  ''We  do  not  wish,  however, 
to  be  understood  as  urging  surgical  intervention  in  every 
case  of  gastric  ulcer.  As  has  already  been  stated,  medical 
treatment  should  always  first  be  tried,  and  only  when 
methodical  and  energetic  medical  treatment  has  failed  to 
cure  the  patient  after  it  has  been  persisted  in  for  a  reason- 
able time,  or  when  several  temporary  cures  have  resulted 
in  ultimate  relapses — only  then,  we  repeat,  is  surgical 
treatment  to  be  considered  in  patients  with  acute,  actively 
ulcerating  lesions." 

It  is  always  necessary  to  pay  special  attention  to  the  diet 
after  stomach  operations  in  order  to  achieve  the  most  favor- 
able results.  It  is  certainly  surprising  to  observe  that  a 
patient,  compelled  for  years  to  live  on  milk,  broth,  and  soups 
is  allowed  at  once  to  partake  of  roast  beef  and  potatoes. 
It  is  an  overestimation  of  surgical  effect  to  suppose  that 
a  stomach  which  has  been  seriously  impaired  for  a  number 
of  years  can  suddenly  develop  normal  function.  It  is 
irrational  to  allow  such  a  patient  to  get  out  of  bed  after 
a  couple  of  weeks  and  to  discharge  him  as  cured  at  the  end 
of  three  weeks.  After  the  operation  a  careful  dietary  should 
be  maintained  for  weeks  and  even  months.  The  surgeon 
should  be  assisted  in  the  care  of  such  convalescents  by  an 
internist.  This  course,  together  with  the  simultaneous  use 
of   alkalies,  constitutes  the  best  method  of   avoiding  the 

'  Boston  Medical  and  yurgiral  Journal,  November  11,  1909,  p.  719. 
'  Surgery  of  the  Upper  Alxlonicii,  1909,  p.  109. 


7A^  GASTRIC   ULCER  207 

danger  of  new  formation,  especially  of  ulcer  of  the  jejunum, 
in  which  location  an  ulcer  is  apt  to  come  as  a  sequela  of 
gastroenterostomy. 

One  of  the  most  frequent  complications  of  gastric  ulcer 
is  hemorrhage.  Acute  hemorrhage  is  not  a  condition  that 
lends  itself  to  surgical  treatment.  Such  hemorrhages  can 
usually  be  stopped  by  internal  measures,  and  if  these  should 
fail,  operative  intervention  is  not  likely  to  help.  Less  than 
5  per  cent,  die  of  these  hemorrhages  without  operation. 
By  subjecting  patients  to  operation  we  expose  them  to 
further  dangers,  to  which  they  easily  succumb;  without 
operation  they  have  a  better  chance  of  recovery.  This 
view  is  shared  by  a  large  number  of  experienced  surgeons. 
As  a  matter  of  fact,  few  cases  of  gastric  hemorrhage  have 
been  lost  when  proper  therapeutic  measures  were  instituted. 
Lenhartz  reports  201  cases  of  gastric  hemorrhage  that  were 
given  internal  treatment,  with  a  mortality  of  3  per  cent.; 
Ewald  166  cases,  with  a  mortality  of  4.8  per  cent.;  and 
Wirsberg  reports  320  cases,  with  a  mortality  of  5.9  per  cent. 
Ligation  of  the  arteries  which  supply  the  ulcer  is  not  to  be 
endorsed,  since  non-surgical  measures  have  been  found  to  be 
more  satisfactory. 

Should  energetic  internal  treatment  not  be  successful, 
chronic  oozing  of  blood  from  the  ulcer  leading  to  anemia  of 
a  pronounced  type,  and  daily  examination  of  the  feces  with 
the  benzidin  test  showing  occult  blood,  operative  treatment 
should  be  advised.  Either  resection  of  the  ulcer  or,  where 
this  is  impossible,  gastroenterostomy  should  be  done.  The 
latter  operation  frequently  stops  the  hemorrhage,  especially 
if  the  ulcer  is  situated  at  the  pylorus.  In  pyloric  ulcer,  how^- 
ever,  it  is  not  the  hemorrhage  but  the  stenosis  which  renders 
operation  imperative.  In  cases  which  do  not  improve  after 
a  prolonged  course  of  internal  treatment  and  in  which  pyloric 
obstruction  is  not  present,  it  is  unwise  to  promise  recovery 
by  means  of  gastroenterostomy.  Surgeons  agree  that  good 
results  by  gastroenterostomy  in  ulcers  of  the  stomach  are 
obtained  only  when  there  is  a  pyloric  obstruction.  Gastro- 
enterostomy does  not  give  drainage  and  physiologic  rest  when 


208         INDICATIONS  FOR  SURGICAL  INTERVENTION 

the  pylorus  is  patulous.  Cannon  and  Blake^  have  shown  that 
food  and  liquids  pass  through  the  pylorus  even  after  gastro- 
enterostomy has  been  performed.  The  artificial  opening 
does  not  help  matters  so  long  as  the  pylorus  is  patent. 

The  conclusions  of  Cannon^  bearing  on  this  question  are 
important.  He  says:  ''According  to  physiologic  obser- 
vations, there  is  no  alteration  of  peristalsis  because  of  a 
new  opening  being  made  midway  in  the  stomach.  The 
notion  which  has  been  expressed  by  some  surgeons  that 
such  an  opening  gives  the  part  of  the  stomach  beyond 
it  rest  from  activity  is  quite  erroneous.  If  the  pjdorus  is 
not  obstructed,  this  continued  peristalsis  results  in  forcing 
food  through  the  normal  exit  at  the  pylorus.  The  physi- 
ologist has  difficulty  in  seeing  any  advantage  gained  by 
this  operation  under  these  circumstances  unless  the  passage 
of  bile  and  pancreatic  juice  into  the  stomach  reduces  hyper- 
acidity, and  experienced  surgeons  now  counsel  against  the 
operation  unless  pyloric  obstruction  is  present.  If  obstruc- 
tion is  present,  food  leaves  the  stomach  through  the  artificial 
opening,  and,  though  the  acid  chyme  doubtless  causes  a 
flow  of  pancreatic  juice  and  bile,  it  may  not  receive  a  proper 
admixture  of  these  juices.  As  a  consequence,  a  considerable 
amount  of  the  fat  and  the  protein  of  the  food  may  pass 
through  the  alimentary  canal  without  being  absorbed." 

Another  dangerous  comphcation  of  gastric  ulcer  is  perfo- 
ration into  the  abdominal  cavity,  followed  by  peritonitis 
or  by  subphrenic  abscess.  This  comphcation  requires 
immediate  surgical  intervention. 

Perforation  in  Gastric  Ulcer. — Statistics  show  that  the  site  of 
gastric  ulcer  is,  as  a  rule,  on  the  posterior  wall  of  the  stomach, 
yet  perforations  occur  most  frequently  from  ulcers  on  the 
anterior  wall.  They  break  by  sloughing  through  the  anterior 
wall  directly  into  the  peritoneal  cavity.  A  sudden  severe 
burning  pain  in  the  epigastric  or  umbilical  region  is  probably 
the  first  symptom  of  a  perforation.  The  pain  is  character- 
istic, inasmuch  as  it   never  shoots  from  one  i^irt  of  the 

'  Annals  of  Surgery,  May,  190."). 

2  Boston  Medical  and  SurKical  Jouinal,  Xovf-iiihcr  11,  I'.XI'.t,  p.  722. 


IN  PYLORIC  STENOSIS  209 

abdomen  to  another,  but  remains  localized.  Frequently 
it  is  so  severe  as  to  compel  the  patient  to  cry  out,  and  is 
often  followed  by  collapse,  sudden  pallor,  a  quick,  feeble 
pulse,  cold  clammy  skin,  and  anxious  countenance.  The 
passage  of  air  from  within  the  stomach  into  the  peritoneal 
cavity  will  immediately  produce  an  effect  on  the  sym- 
pathetic nerves,  resulting  in  shock,  when,  owing  to  the 
obtunded  senses,  pain  disappears.  Acute  pain,  fall  of  tem- 
perature, rapid  pulse,  vomiting,  tenderness  in  the  epigas- 
trium, rigidity  and  shock,  demand  immediate  surgical 
intervention.  The  operation  should  take  place  within  ten 
hours  after  perforation — when  the  mortaUty  is  about  28  per 
cent.  According  to  statistics,  the  mortality  rises  to  65  per 
cent,  if  the  operation  be  delayed  more  than  twenty-four 
hours,  and  to  87  per  cent,  after  thirty-six  hours;  undertaken 
later,  operation  offers  no  hope.  The  operation  may  be 
very  simple  for  perforation  at  the  greater  and  lesser 
curvatures  and  at  the  anterior  wall  of  the  stomach.  If 
the  perforation  has  taken  place  at  the  posterior  wall  the 
operation  is  most  difficult  and  usually  does  not  do  any 
good. 

The  statistics  in  perforation  show  such  unfavorable  results 
from  internal  treatment  that  it  seems  imperative  to  resort 
at  once  to  surgery  unless  there  are  very  important  consider- 
ations to  contraindicate  it. 

Subphrenic  abscess  following  perforation  should  likewise 
be  operated  upon  as  soon  as  possible.  The  most  frequent 
cause  of  such  suppuration  is  gastric  ulcer;  it  is  rare  to 
find  it  following  any  other  disease.  The  abscess  may  be 
subhepatic  or  retrocolic. 

Pyloric  Stenosis. — The  surgically  most  important  com- 
plication of  gastric  ulcer  is  benign  pyloric  stenosis  with 
subsequent  dilatation  of  the  stomach.  The  diagnosis  is 
dependent  upon : 

1.  The  history  pointing  to  ulcer. 

2.  Vomiting  of  a  large  proportion  of  the  food  ingested 
on  the  previous  day. 

3.  Decreased  secretion  of  urine. 

14 


210         INDICATIONS  FOR  SURGICAL  INTERVENTION 

4.  The  presence  of  food  remnants  in  the  morning  before 
breakfast. 

5.  The  chemic  findings :  hyperacidity  or  hyperchlorhydria. 

6.  The  microscopic  findings:  sarcinse  in  the  gastric  con- 
tents. 

Benign  pyloric  stenosis  may  be  occasioned  by  compres- 
sion from  tumors  of  the  Hver,  the  gall-bladder,  or  the  pan- 
creas, by  adhesions,  by  true  cicatricial  constriction,  or  by 
spastic  contraction  of  the  pylorus.  The  most  common  cause 
is  the  contraction  of  a  cicatrix  from  a  previous  ulcer.  Unless 
there  is  a  critical  condition,  such  as  exhaustion,  tetany  or 
impending  tetanj,  or  uncontrollable  vomiting,  we  should, 
after  having  arrived  at  the  diagnosis  of  benign  pyloric 
stenosis,  attempt  to  relieve  the  engorgement  by  rational  diet 
(fluid  and  gruels)  and  nourishing  enemata,  and  also  by  cata- 
plasms, irrigations  of  the  stomach,  and  oil  therapy  by  mouth. 
Should  this  line  of  treatment  prove  successful,  the  daily 
secretion  of  urine  increasing  to  normal,  and  the  patient  show- 
ing uninterrupted  improvement  from  week  to  week,  with  no 
retention  even  after  an  increased  dietary,  operation  is  not  indi- 
cated, because  the  case  is  one  of  gastric  congestion  caused  by 
a  spastic  stenosis  and  not  by  a  cicatricial  condition.  If  all 
other  symptoms  improve  but  there  are  still  food  remnants 
early  in  the  morning  after  enlarging  the  range  of  foods,  the 
operation  should  not  be  delayed,  particularly  with  patients 
who,  from  their  position  in  life,  are  not  able  to  continually 
confine  their  diet  within  the  required  limits.  In  cicatricial 
stenosis  of  the  pylorus  the  results  of  gastroenterostomy  are 
excellent. 

A  pathologic  change  in  the  duodenum  similar  to  that 
in  the  pylorus  is  apt  to  produce  the  same  sjanptoms  of 
obstruction.    The  conditions  may  be  various: 

1.  Change  in  the  wall  of  the  pjdorus. 

2.  Change  in  the  lumen  of  the  pylorus. 

3.  Change  in  the  route  b}'^  distortion. 

4.  Change  in  the  route  by  pressure. 

The  condition  causing  a  stenosis  which  responds  well  to 
surgery  is  that  in  which  there  has  been  an  ulcer  and  the 


IN  ACUTE  DILATATION  OF  THE  STOMACH  211 

cicatricial  and  hyperplastic  changes  have  closed  the  lumen. 
Temporary  obstruction  of  the  pylorus  never  produces 
dilatation,  which  condition  is  usually  found  in  obstruction 
following  ulcer  or  malignant  tumor.  The  Roentgenogram  has 
been  found  a  valuable  aid  in  the  diagnosis  of  dilatation  of  the 
stomach  (Plates  XX  and  XXI).  The  stomach  in  dilatation 
must  be  differentiated  from  a  large  normal  stomach  (megalo- 
gastria),  and  this  can  easily  be  done  by  examination  of  the 
stomach  contents.  Gastroptosis  may  be  mistaken  for  dila- 
tation. A  displaced  stomach  can  be  located  an^-i^^here,  even 
to  the  symphysis  pubis.  If  the  stomach  empties  itself  at  the 
proper  time— that  is,  if  there  is  no  stagnation  of  the  gastric 
contents — we  may  exclude  dilatation. 

The  operations  for  the  rehef  of  benign  obstruction  of 
the  pylorus  are :  pyloroplasty,  gastroduodenostomy,  gastro- 
enterostomy. The  method  and  selection  of  the  operation 
will  depend  upon  the  conditions  at  the  time  of  operation. 
In  the  operation  of  pyloroplasty,  adhesions  may  result  which 
will  fix  the  pyloric  exit  at  a  high  level.  When  the  muscle 
fibres  are  weak,  it  may  be  difficult  for  the  stomach  to  lift  the 
food  up  through  the  outlet  (Mayo). 

Acute  Dilatation  of  the  Stomach. — This  condition  is  found  as 
a  postoperative  complication,  and  may  terminate  in  death 
within  thirty-six  hours.  Patients  complain  of  pain  in  the 
epigastrium.  The  splashing  sound  may  be  elicited  over 
the  abdomen,  and  the  stomach  may  fill  the  whole  cavity. 
Vomiting  of  large  quantities  of  dark  greenish  material 
takes  place  and  may  continue  to  death  or  recovery.  The 
vomitus  usually  consists  of  gastric  secretion,  mucus,  blood, 
and  bile,  seldom  of  fecal  material.  The  stomach  tube 
relieves  the  patient  at  once  of  much  liquid  and  gas  and  pro- 
duces a  flattening  of  the  protuberance  of  the  abdomen. 
The  stomach  should  be  washed  out  with  one  pint  of  normal 
saline,  after  which  the  patient  usually  makes  a  complete 
recovery.  Again,  there  may  be  cases  where  the  stomach 
will  refill  with  gastric  secretion  and  air.  If  after  repeated 
lavage  the  patient  does  not  recover,  he  should  be  told  to 
lie  on  his  stomach  and  endeavor  to  empty  it  as  described 


212         INDICATIONS  FOR  SURGICAL  INTERVENTION 

on  page  124.  Patients  should  alwaj^s  lie  on  their  right  side 
to  assist  in  emptying  the  stomach  contents  through  the 
pylorus.  The  patient  may  be  placed  in  the  Trendelenburg 
position,  a  stomach  tube  being  used  for  drainage.  When 
these  measures  fail,  gastroenterostomy  is  indicated.  Autopsy 
records  show  that  in  some  cases  of  postoperative  acute  dila- 
tation of  the  stomach  there  is  a  kinking  of  the  intestine 
above  the  duodenojejunal  juncture  or  a  pyloric  stenosis. 

Gastric  Tetany. — Kussmaul  was  the  first  to  draw  our  atten- 
tion to  the  fact  that  in  certain  cases  of  dilatation  of  the 
stomach  tetanoid  spasms  occur.  We  now  know  that  there 
are  several  conditions  of  the  gastro-intestinal  tract  which 
may  cause  convulsive  attacks.  Robson  and  Moynihan' 
believe  that  the  appropriate  treatment  in  all  cases  of 
gastric  tetany  is  surgical.  They  conclude  that  in  almost 
all  cases  there  is  a  grave  mechanical  obstacle  to  the  onward 
passage  of  food.  It  is  this  obstacle  which  causes  dilatation 
and  hypertrophy  of  the  stomach.  To  relieve  the  obstruction 
and  to  prevent  stagnation  of  the  stomach  contents,  surgical 
measures  are  necessary.  They  report  several  recoveries 
after  surgical  intervention. 

In  dilatation  of  the  stomach  resulting  from  atrophy  of 
the  muscle  fibres,  when  the  pylorus  functionates  normally, 
operation  is  indicated  only  in  exceptional  cases.  It  should 
be  regarded  as  called  for  only  after  all  internal  therapy,  such 
as  irrigation  of  the  stomach,  diet,  tonics,  massage,  electricity, 
and  hydropathic  measures,  have  proved  to  be  complete 
failures. 

The  differential  diagnosis  between  atony  and  secondary 
dilatation  following  pyloric  stenosis  is  often  a  difficult  matter. 
It  depends  upon  the  objective  findings  and  upon  a  history 
of  ulcer  manifestations.  Gastric  rigidity  and  pyloric  tumor 
point  to  stenosis.  If,  in  the  absence  of  ulcer  symptoms,  a 
rational  therapy  relieves  the  dilatation,  the  latter  was 
probably  atonic. 

Hypertrophic  Stenosis  of  the  Pylorus. — Hyi)ertro]:)hic  stenosis 
of  the  pylorus  has  been  successfully  operated  upon  in  very 

'  Diseases  of  the  Stomach  and  Tlicir  Surgical  Tieal incut,  I'.IOI,  p.  lit). 


IN  PERIGASTRITIS  213 

young  children.  As  experience  in  these  cases  accumulates 
we  find,  however,  that  internal  treatment  is  often  efficient  and 
surgical  intervention  usually  not  required.  An  important 
point  to  remember  in  this  connection  is  that  we  do  not  know 
how  the  operative  result  of  gastroenterostomy  performed 
upon  young  children  will  regulate  itself  in  advancing  years. 

In  congenital  hypertrophic  stenosis  of  the  pylorus,  a 
child  at  birth  seems  well  nourished,  but  soon  begins  to  vomit 
its  food.  The  quantity  of  vomited  material  increases  from 
day  to  day;  and  alteration  of  food,  modified  or  peptonized 
milk,  seems  to  have  little  or  no  influence  on  the  vomiting, 
which  continues  regardless  of  the  quantity  of  food  taken.  By 
the  use  of  the  stomach  tube  we  find  that  if  there  is  no  vomit- 
ing the  food  taken  is  retained  in  the  stomach  a  long  time. 
The  weight  of  the  child,  meanwhile,  continues  to  decrease 
and  the  little  patient  looks  old  and  wrinkled.  Constipation 
is  usually  present.  The  tongue  and  mouth  are  moist  and 
clean.  Upon  inspection  the  abdomen  is  found  to  be  fiat,  and 
a  peristaltic  wave  can  be  seen  to  pass  over  the  stomach. 
Frequently  the  stomach  contents  may  be  outlined  through 
the  abdominal  wall  and  the  visible  waves  of  peristalsis  easily 
made  out.     An  epigastric  tumor  points  to  pyloric  stenosis. 

Regarding  congenital  stenosis,  Deaver  and  Ashhurst^ 
state  as  follows:  ''It  is  needless  to  say  that  medicinal 
treatment  should  first  be  extensively  tried;  and  it  is  our 
behef  that  in  the  immense  majority  of  cases  medical  treat- 
ment promptly  instituted  and  energetically  applied  will  be 
successful  in  curing  the  patient."  Thorough  internal  treat- 
ment, as  stated  in  the  chapter  on  Pyloric  Stenosis,  failing, 
surgical  intervention  is  necessary.  When  inflammation  of  the 
peritoneal  coat  of  the  stomach  occurs,  we  are  apt  to  have 
adhesions. 

Perigastritis. — In  rare  cases  there  may  be  an  adhesion 
near  the  pylorus,  predisposing  to  dilatation,  that  leads  us 
to  believe  we  have  a  case  of  organic  obstruction  of  the 
pylorus.  Morris  has  called  our  attention  to  adhesions  in 
the  abdomen,  which  he  calls  "cobwebs,"  that  may  cause 

^  Surgery  of  the  Stomach  and  Duodenum,  1909,  p.  139. 


214         INDICATIONS  FOR  SURGICAL  INTERVENTION 

many  symptoms  of  indigestion.  When  these  adhesions  occur 
around  the  stomach,  interfering  with  motihty,  thej^  may 
produce  symptoms  suggesting  dilatation.  The  methods  of 
examination  mentioned  in  the  chapter  on  Motor  Insuffi- 
ciency will  help  us  in  the  diagnosis. 

In  regard  to  adhesions  and  perigastritis  we  are,  unfortu- 
nately, able  to  make  a  diagnosis  in  only  a  very  small  per- 
centage of  cases.  Perigastritis,  unless  there  is  a  distinct 
disturbance  of  motility,  is  rarely  a  sufficient  reason  for 
surgical  intervention.  When  firm,  immovable  tumors  can 
be  palpated  in  the  epigastrium,  and  carcinoma  can  be  ex- 
cluded, the  existence  of  adhesions  or  epigastric  hernia  may 
be  suspected.  Adhesions  may  or  may  not  interfere  with 
the  motility  of  the  stomach.  Those  not  interfering  ma}'  be 
wisely  left  undisturbed,  for  we  all  know  that  severed  adhe- 
sions are  likely  to  re-form.  For  adhesions  that  interfere  with 
gastric  motility,  fibrolysin  by  the  hypodermic  method  may 
be  tried  (see  page  414),  and  should  this  fail,  the  case  must 
be  turned  over  to  the  surgeon. 

Hourglass  Contraction. — Hourglass  stomach  is  a  condition 
in  which  the  stomach  is  divided  into  two  cavities.  It  may 
be  either  congenital  or  acquired.  The  hourglass  stomach, 
so  called,  is  caused  by  perigastric  adhesions  or  gastric  ulcer. 
The  diagnosis  depends  in  the  main  upon  the  use  of  the 
stomach  tube,  when  by  inspection  one  ma}''  be  able  to  see 
that  the  fluid  introduced  into  the  stomach  through  the 
stomach  tube  produces  a  ballooning  or  prominence  of  one 
part  of  the  stomach,  and  that  this  prominence  suddenly  sub- 
sides and  after  a  gurgling  noise  another  swelling  shows  itself 
in  the  other  part  of  the  stomach.  The  rr-ray  and  bisnuith 
suspension  afford  the  best  means  of  diagnosis.  The  treatment 
of  hourglass  stomach  is  always  surgical. 

Gastroptosis. — In  gastroptosis  surgeons  have  attempted  to 
estabhsh  normal  conditions  through  ventrofixation,  by 
shortening  the  gastrocolic  and  gastroduodenal  ligaments  and 
gathering  up  the  mesocolon.  My  experience  has  taught 
me  to  withhold  my  approval  fi'om  those  procedures,  since 
I  have  seen  so  nianv  instances  in  whicli  tliev  have  created 


IN  CARCINOMA  215 

new  troubles  without  removing  the  old.  I  am  still  of  the 
conviction  that  gastroptosis  should  be  treated  altogether 
by  mechanical,  dietetic,  physical  and  medicinal  means.  (See 
chapter  on  Gastroptosis.) 

Deaver  and  Ashhurst^  say  that  'SSurgical  treatment  is 
rarely  called  for  in  cases  of  simple  gastroptosis;  when  suc- 
cessful, it  is  rather  because  the  stomach  was  dilated,  and 
because  by  operation  its  motility  is  improved,  than  because 
malposition  has  been  corrected."  They  conclude  as  follows: 
"Finalty,  it  may  be  well  to  insist  again  upon  the  impro- 
priety of  performing  any  operation  in  the  majority  of  cases 
of  gastroptosis.  Much  comfort,  indeed  an  almost  complete 
rehef  from  invalidism,  may  frequently  be  obtained  by  the 
use  of  a  well-fitting  abdominal  binder.  An  ill-fitting  belt 
is  worse  than  useless."  The  most  rational  method  of 
treatment  in  cases  where  the  ptosis  has  caused  a  kink  at  the 
pylorus  or  duodenum  seems  to  be  gastroenterostomy. 

Gastroplication  is  a  surgical  procedure  to  reduce  the  size 
of  the  stomach  by  folding  or  gathering  the  gastric  walls. 
It  is  seldom  indicated,  and  the  results  are  not  good.  It 
has  been  used  in  atony  and  dilatation.  The  causes  of  atony 
and  dilatation  require  treatment  rather  than  the  conditions 
themselves. 

Carcinoma. — Carcinoma  of  the  stomach,  when  diagnosticated 
early,  should  be  operated  upon  at  once.  Even  if  the  diag- 
nosis be  doubtful,  no  harm  is  done,  in  the  hands  of  a  good 
operator,  by  exploratory  incision.  Indiscriminate  explor- 
atory incision  brings  disrepute  to  surgeons  and  no  benefit 
to  the  patient. 

It  is  sad  to  think  that  among  the  alarmingly  large  number 
of  gastric  cancer  cases  there  are  so  comparatively  few  cures  to 
report.  The  reason  is  that  we  resort  to  operation  when  it  is 
too  late.  The  great  necessity  for  early  diagnosis  of  carcinoma 
must  be  emphasized.  What  is  an  early  diagnosis?  It  is  a 
diagnosis  of  carcinoma  during  the  stage  when  the  growth  is 
still  circumscribed  and  metastasis  has  not  taken  place.  At 
this  time  radical  operation  is  possible.    A  diagnosis  of  cancer 

1  Surgery  of  the  Stomach  and  Duodenum,  1909,  pp.  176  to  178. 


216         INDICATIONS  FOR  SURGICAL  INTERVENTION 

in  the  very  early  stage  of  its  growth  can  rarely  be  made. 
I  might  cite  a  number  of  cases  demonstrating  that  we  are 
far  from  being  able  to  make  a  diagnosis  with  certainty,  even 
with  the  aid  of  exploratory  laparotomy.  It  may  happen, 
as  I  have  seen,  that  operation  is  performed  at  a  very  early 
stage,  at  the  time  of  the  fii^st  manifestations  of  the  disease, 
and  metastases  both  small  and  large  are  found  but  no 
primary  tumor.  I  have  even  had  exploratory  incision  made 
in  cases  of  suspected  cancer  of  the  stomach  where  no  lesions 
were  found,  yet  carcinoma  with  all  its  manifestations  con- 
tinued to  develop  and  subsequently  proved  fatal  to  the 
patient.  On  the  other  hand,  there  may  be  an  occasional 
case  with  a  large  and  apparently  inoperable  tumor,  and  at 
autopsy  it  is  discovered  that  there  are  no  metastases  and 
the  tumor  could  have  been  removed  without  difficulty. 

Findings  which  are  supposed  to  be  a  safe  guide  for  the 
early  recognition  of  carcinoma  are  sometimes  very  mislead- 
ing. Great  importance  is  to  be  attached  to  the  history — 
whether  there  was  at  any  time  gastric  ulcer,  gastritis,  chole- 
lithiasis, or  whether  the  affection  has  developed  insidiously. 
Loss  of  appetite,  repugnance  to  food,  eructations,  vomiting, 
debility,  decrease  in  weight,  are  points  to  be  considered. 
There  should  be  repeated  examinations  of  the  entire  body 
and  a  study  of  the  gastric  functions,  including  tests  for  the 
absence  or  deficiency  of  hydrochloric  acid  and  for  the  pres- 
ence of  lactic  acid  and  blood.  Microscopic  examination  of 
the  stomach  contents  should  not  be  omitted.  Special  atten- 
tion should  be  paid  to  disturbed  motihty,  to  the  presence 
of  food  remnants  in  the  stomach,  and  to  the  recognition  of 
occult  blood  in  the  feces.  I  consider  retention  the  most  im- 
portant symptom  and  the  most  important  indication  for 
immediate  operation  when  there  is  the  slightest  suspicion  of 
carcinoma.  Examination  of  the  contents  of  the  stomach 
after  a  long-continued  fluid  diet  is  not  sufficient.  The  gastric 
contents  should  be  examined  after  the  ])atient  has  ])ar(aken 
for  one  or  two  days  of  a  diet  difficult  of  digestion,  containing 
such  foods  as  apples,  ])lums,  currants,  cherries,  and  sausage. 
If  after  feeding  the  ])atient  on  such  food  gastric  retention 


IN  CARCINOMA  217 

is  found  on  examination  of  the  stomach  contents  made 
before  breakfast,  interference  with  motiUty  is  certain. 

The  secretion  of  hydrochloric  acid  and  pepsin  is  usually 
decreased  as  the  carcinoma  develops,  and  in  an  advanced 
stage  of  the  disease  is  inhibited  altogether,  except  in  carci- 
noma developing  from  gastric  ulcer,  when  even  hyperacidity 
may  exist.  The  presence  or  absence  of  hydrochloric  acid 
is  significant  only  in  connection  with  all  the  other  symptoms 
and  findings.  Lactic  acid  is  not  a  specific  sign  of  carcinoma, 
for  not  only  is  it  frequently  absent  in  undoubted  cases,  but 
it  is  sometimes  present  when  there  is  no  carcinoma.  There 
is  no  doubt  that  its  presence  distinctly  points  to  carcinoma, 
but  not  infalUbly  so.  AVhen  hj^drochloric  acid  is  present, 
lactic  acid  is  invariably  absent. 

If  there  is  persistent  vomiting,  which  all  measures  fail  to 
relieve,  exploratory  operation  is  indicated.  If  hematemesis 
and  signs  of  pyloric  obstruction  and  dilatation  be  associated 
with  the  vomiting,  the  indications  for  prompt  surgical  inter- 
vention are  very  definite. 

Surgeons  demand  an  exploratory  laparotomy  in  every 
case  in  which  the  diagnosis  is  in  the  least  doubtful  and 
in  cases  which  do  not  yield  immediately  to  internal  treat- 
ment. The  number  of  cases  we  should  have  to  subject  to 
laparotomy  to  no  purpose  would  be  very  large,  were  we  to 
satisfy  the  demands  of  surgeons  to  perform  an  exploratory 
operation  in  all  doubtful  cases.  Moreover,  this  is  much 
easier  said  than  done.  Patients  complain  of  comparatively 
little  trouble,  which  msiy  be  occasioned  by  an  incipient 
carcinoma,  or  equally  as  well  by  a  neurosis,  gastritis,  erosion, 
ulcer,  gastroptosis,  cholelithiasis,  or  by  disturbed  gastric 
function  originating  in  disorders  of  remote  organs.  When 
it  is  considered  that  two-thirds  of  all  chi'onic  diseases  of 
the  stomach  belong  to  the  type  of  neuroses  or  functional 
disorders,  we  can  readily  understand  why  the  internist 
hesitates  when  the  surgeon  demands  exploratory  incision. 
Consideration  of  all  the  points  of  the  examination,  careful 
observation,  and  in  some  cases  rational  internal  treatment, 
are  required  in  order  that  an  opinion  may  be  formed.     The 


218         IXDICATIOXS  FOR  SURGICAL  INTERVENTION 

procedures  necessary  for  making  a  posith^e  diagnosis  in  some 
cases  are  beset  with  difficulties.  There  are  two  reasons  in 
particular  for  this:  The  stomach  continues  to  perform  its 
normal  functions  for  a  considerable  time  after  the  initiation 
of  the  carcinomatous  process;  and  patients,  deceived  by  the 
mildness  of  their  sjTnptoms  at  the  beginning  of  the  disease, 
object  to  the  frequent  and  detailed  examinations  necessarj^, 
and  in  many  instances  will  not  return  and  submit  to  them. 

If  the  ailment  has  a  tendency  to  exacerbation  and  all 
attempts  to  stimulate  the  appetite  fail,  if  vomiting  proves 
obstinate  and  uncontrollable  and  the  bodj^  weight  does  not 
show  an  increase,  we  may  suspect  the  presence  of  carcinoma, 
and  are  obliged  to  advise  an  exploratory  laparotomy  even 
if  no  tumor  be  palpable.  If,  on  the  other  hand,  there  is 
an  increase  in  weight  of  one  or  two  pounds  every  week, 
with  improvement  in  appetite  and  the  patient's  appear- 
ance and  sensation  of  well-being,  and  if  the  luifavorable 
symptoms  decrease,  particularly  the  failing  secretion  of 
hydrochloric  acid,  we  may  in  most  cases  exclude  carcinoma. 
With  all  possible  precautions,  however,  mistaken  diagnoses 
cannot  altogether  be  avoided. 

It  must  be  admitted  further  that,  while  exploratory 
laparotomy  is  no  longer  a  serious  operation,  it  is  not  entirely 
free  from  danger.  If  we  advise  exploratory  laparotomy 
when  the  manifestations  of  disease  are  slight,  the  majority 
of  patients  will  not  submit,  and  if  after  such  refusal  a  course 
of  internal  treatment  is  instituted  and  the  patients  recover 
we  shall  subject  ourselves  to  many  unjust  reproaches.  An 
important  point  to  remember  is  that  upon  examining  an 
opened  stomach  it  may  be  very  difficult  for  the  surgeon  to 
interpret  correctly  the  traces  of  a  possible  old  ulcer  or  other 
finding.  What  he  may  judge  to  be  benign  frequently  proves 
to  be  malignant,  and  what  seems  to  him  malignant  may 
be  benign. 

Carcinoma  at  the  fundus  and  body  of  \ho  stomach 
generally  manifests  itself  only  at  a  time  so  late  in  its  develop- 
ment that  radical  operation  can  offer  little  hope.  Successful 
resection  can  only  be  hoped  for  in  carcinoma  of  the  pylorus 


IN  CARCINOMA  219 

and  of  the  lesser  curvature,  the  latter  encroaching  upon  the 
pylorus  at  an  early  stage.  These  cases  constitute  about 
50  per  cent,  of  all  cases  of  gastric  cancer.  When  resection 
is  possible  it  should  always  be  done.  The  size  of  the  tumor 
is  no  contraindication,  so  long  as  the  stomach  is  large. 

An  important  question  to  consider  is,  whether  an  operation 
is  justifiable  when  there  are  metastases  though  the  cancer  in 
the  stomach  is  of  such  a  character  that  it  can  be  removed; 
and  whether  in  such  a  case  gastroenterostomy  or  resection 
should  be  the  chosen  operation.  Though  the  results  of 
gastroenterostomy  in  cases  of  benign  pyloric  stenosis  are 
good,  in  cancer  they  are,  with  few  exceptions,  sadly  deficient. 
The  average  success  with  a  gastroenterostomy  in  cancer  con- 
sists in  the  prolongation  of  life  for  six  months.  Experience 
shows  that  resection  gives  better  results.  In  cases  with  slight 
metastases  resection  should  be  given  the  preference,  if  pos- 
sible, over  gastroenterostomy.  With  the  present  improved 
technique  it  is  possible  to  perform  a  complete  resection  in 
one  to  one  and  one-half  hours. 

Gastroenterostomy  is  indicated  only  in  pyloric  carcinoma 
with  retention  when  resection  is  no  longer  possible.  If 
there  is  the  slightest  doubt  as  to  the  benign  character  of 
the  pyloric  stenosis,  resection  of  the  pylorus  is  indicated. 
The  mortality  in  resection,  according  to  the  statistics  of 
various  prominent  surgeons,  is  between  6  and  28  per  cent., 
or  an  average  of  17  per  cent.  The  average  duration  of 
life  after  a  resection  is  from  sixteen  to  eighteen  months. 
William  J.  Mayo,  at  the  1909  meeting  of  the  American 
Gastroenterological  Association,  said,  regarding  cancer  of 
the  stomach:  "1  think  it  was  a  great  mistake  when  Koenig 
said  that  patients  with  cancer  of  the  stomach  who  had  a 
palpable  tumor  were  incurable.  We  have  one  such  patient 
who  has  survived  a  gastrectomy  five  years,  and  some  others 
three  or  four  years,  and  we  do  not  consider  a  movable 
tumor  necessarily  a  contraindication  to  operation.  Obstruc- 
tion and  a  movable  tumor,  one  or  both,  indicate  surgical 
consultation." 


CHAPTER    X 


ALTERATIONS  IN  THE  POSITION  OF  THE  STOMACH  AND  OTHER 
ABDOMINAL  ORGANS:  GASTROPTOSIS  —  ENTEROPTOSIS— 
NEPHROPTOSIS— HEPATOPTOSIS— SPLENOPTOSIS 


Gastroptosis,  a  term  for  which  we  are  indebted  to  Glenard, 
is  so  frequently  compUcated  with  displacement  of  the  other 
abdominal  organs  that  it  may  be  considered  conveniently 
under  the  heading  of  Enteroptosis.  Separate  names  have 
been  given  to  the  downward  displacement  of  abdominal 
viscera,  among  which  we  have  gastroptosis,  referring  to 
downward  displacement  of  the  stomach;  coloptosis,  or 
downward  displacement  of  the  colon;  hepatoptosis,  spleno- 
ptosis, nephroptosis,  enteroptosis,  referring  respectively  to 
downward  displacement  of  the  liver,  spleen,  kidney,  and 
intestine. 

The  etiology  and  clinical  manifestations  of  these  condi- 
tions, as  well  as  their  treatment,  are  so  similar  that  they 
may  be  considered  with  advantage  together.  Much  has 
been  written  on  the  subject  by  both  American  and  Euro- 
pean authors,  notably  Virchow,  Glenard,  Landau,  Langer- 
hans,  Kuttner,  Ewald,  Stiller,  Boas,  and  Meinert,  abroad; 
and  Einhorn,  Hemmeter,  Bettmann,  Lichty,  Stockton, 
Webster,  Steele,  Lockwood,  Roosing,  Dyer,  McPhedran, 
Kellogg,  Robinson,  and  Spivak,  in  this  country. 

Etiology. — Enteroptosis  is  a  condition  frecjuently  met  with 
in  patients  who  consult  a  physician  in  regard  to  digestive 
disturbances.  It  is  a  disease  of  comparative!}'  young  adult 
life,  appearing  soon  after  puberty;  it  is  rarely  mot  with  in 
patients  over  fifty  years  of  age. 

Females  are  particularly  disposed  to  enteroptosis.  Prob- 
ably the  greater  munbor  of  cases  are  lo  bo  found  among  Ihe 
working  classes. 


ENTEROl'TOSIS 


221 


Fit:.  24 


Forms. — From  the  viow-poiiit  of  etiology  two  different 
forms  of  enteroptosis  are  to  be  distinguished.  The  first  is 
the  result  of  causes  acting  mechanically,  the  principal 
etiologic  factors  being  improper  modes  of  dress,  trau- 
matism, frequent  childbirth,  and  tight 
lacing;  all  these  causes  are  aided  by  poor 
nutrition  and  severe  physical  toil.  This 
form  of  enteroptosis  comprises  a  com- 
paratively small  number  of  cases.  Fre- 
quent pregnancies,  by  bringing  about  a 
condition  of  relaxation  of  the  abdominal 
wall  and  of  the  recti  muscles,  producing 
thereby  a  pendulous  abdomen,  are  re- 
sponsible for  many  of  these  cases  of  en- 
teroptosis. It  has  been  shown  repeatedly 
that  tight  lacing  is  productive  of  down- 
ward dislocation  of  the  intestine.  The 
removal  of  large  abdominal  tumors, 
and  frequent  paracenteses  in  order  to 
free  the  abdomen  of  ascitic  fluid,  are 
also  etiologic  factors  in  enteroptosis. 
Organic  diseases  in  general  may  like- 
wise lead  to  ptosis  of  the  stomach.  The 
causal  relation  between  trauma  of  the 
abdomen  and  displacement  of  the  kidney 
is  well  known. 

The  second  form  of  enteroptosis  is 
due  to  a  constitutional  hereditary  pre- 
disposition.     Thanks  to  the  researches 
of  Stiller,  more  is  understood   of  this 
variety  of  downward  displacement  than 
formerly,  and  his  views  are  now  almost 
universally  accepted.    According  to  this 
writer,  in  90  per  cent,  of  cases  of  entero- 
ptosis the  abnormal  position  of  the  abdominal  viscera  is  quite 
a  distinct  form  of  the  physical  conformation.      Stiller  speaks 
of  universal  asthenia  of  a  congenital  nature,  or,  as  he  calls  it, 
' '  habitus  enteroptoticus  "  (Fig.  24) .      Patients  suffering  from 


Habitus    enteroptoticus 
(asthenia  universalis). 


222     ALTERATIONS  IN  POSITION  OF    ABDOMINAL    ORGANS 

this  weakness  and  from  the  characteristic  bodily  form  are  apt 
to  develop  into  neurasthenics.  The  condition  of  entero- 
ptosis  is  often  complicated  with  gastric  and  intestinal  atony 
and  nervous  dyspepsia.  A  well-marked  case  of  habitus 
enteroptoticus  presents  a  complex  of  symptoms,  namely, 
those  of  enteroptosis,  gastric  atony,  and  nervous  dyspepsia. 
This  complex  of  symptoms  has  been  designated  general 
asthenia.  These  three  affections  are  not  always  present, 
however,  in  the  same  degree  of  intensity.  Enteroptosis 
gives  rise,  as  a  rule,  to  the  most  pronounced  symptoms.  The 
mechanical  causes  mentioned  above  would  not,  in  all  proba- 
bility, give  rise  to  enteroptosis  were  the  patient  not  pre- 
disposed to  this  condition  b}^  the  habitus  enteroptoticus. 
Hence  it  may  be  concluded  that  enteroptosis  from  purely 
mechanical  causes  is  a  rare  condition. 

Pathology. — Gastroptosis  does  not  impl}^  a  faUing  or  down- 
ward displacement  of  the  entire  stomach.  On  account  of 
the  attachment  of  the  stomach  at  the  cardia  it  is  impossible 
for  the  displacement  to  be  complete;  when  we  speak  of 
gastroptosis,  a  descension  of  the  pylorus  and  that  part  of 
the  stomach  directly  in  front  of  the  vertebral  column  is 
impUed.  With  the  downward  displacement  of  the  pylorus 
there  is  Hkely  to  be  a  stretching  of  the  stomach  from  the 
cardiac  orifice  toward  the  pylorus.  Several  abnormal  con- 
ditions enter  into  the  development  of  both  gastroptosis  and 
enteroptosis.  For  example,  the  ligaments  and  mesentery 
may  become  relaxed,  thus  permitting  a  displacement  of  the 
organs  attached  to  them ;  or  the  intra-abdominal  equilibrium 
may  be  disturbed  by  alteration  of  the  intra-abdominal 
pressure  upon  which  it  depends,  and  enteroptosis  result. 

Symptoms. — Many  patients  with  habitus  enteroptoticus 
which  has  developed  into  pronounced  enteroptosis  do  not 
experience  any  distressing  symptoms  whatever.  The  same 
may  be  said  of  those  whose  enteroptosis  is  the  result  of 
purely  mechanical  processes.  On  the  other  hand,  many 
patients  have  been  relieved  of  the  distressing  symptoms 
accompanying  enteroptosis  without  correction  of  the  ana- 
tomic disj)lacemcnts.     It   may  be  inferred   from  this  that 


ENTEROl'TOSIS  223 

entei'optosis  in  itself  does  not  jiroduce  any  marked  disturb- 
ance or  discomfort  to  the  patient.  A  long-continued  me- 
chanical support  will  not  permanently  restore  the  stomach 
to  its  normal  position.  Steele  and  Francine,^  after  a  year's 
work  investigating  these  conditions  in  the  medical  dispensary 
of  the  University  of  Pennsylvania,  found  that  in  all  cases 
examined  after  a  year  of  constant  mechanical  support  the 
stomach  (unsupported)  was  in  exactly  the  same  position  as 
when  first  examined.  According  to  Stiller,  the  constitutional 
neurasthenia  of  enteroptotics  is  responsible  for  a  great  many 
of  the  distressing  symptoms  ascribed  to  enteroptosis  itself. 
The  displacement  merely  aggravates  the  neurasthenic  effects, 
or  perhaps  in  some  instances  initiates  them  by  the  con- 
tinuous traction  of  the  displaced  viscera  on  the  ligaments, 
thus  placing  the  abdominal  sympathetic  nervous  system 
in  a  condition  of  continued  reflex  irritation.  Atony  of  the 
stomach  and  intestine,  a  frequent  accompaniment  of  well- 
marked  ptosis  of  these  organs,  is  productive  of  many 
untoward  symptoms.  Patients  complain  of  a  variety  of 
nervous  manifestations,  such  as  lassitude,  dull  headache, 
inability  to  work,  mental  depression,  and  general  weakness. 
The  gastric  symptoms  consist  of  pressure,  fulness,  nausea, 
and  belching;  occasionally  pain  is  felt  in  the  region  of  the 
stomach.  These  gastric  symptoms  are  all  due  to  the  atonic 
condition  of  the  stomach.  Indications  of  nervous  dyspepsia 
are  also  in  evidence  as  burning  sensations  in  the  stomach, 
hyperacidity,  and  vague  discomforts  after  eating.  The  ap- 
petite is,  as  a  rule,  poor,  though  on  rare  occasions  patients 
have  ravenous  appetites.  Enteroptosis  is  often  accompanied, 
in  women  particularly,  by  severe  backaches. 

Objective  Symptoms. — The  objective  symptoms  in  cases  of 
well-marked  habitus  enteroptoticus  are  very  characteristic. 
The  patients,  as  a  rule,  are  tall  in  stature,  with  long  arms,  thin 
neck,  narrow,  elongated  thorax,  and  long,  flat  abdomen.  The 
habitus  enteroptoticus  impresses  the  observer  at  first  as  being 
similar  to  the  habitus  phthisicus.  The  bony  structure  is  shght, 
the  muscles  are  weak,  and  there  is  a  marked  diminution  in 

1  Medical  Society  of  Pennsylvania,  September  24,  1903. 


224     ALTERATIONS  IN  POSITION  OF    ABDOMINAL    ORGANS 

the  adipose  tissue  which  gives  grace  to  the  physical  appear- 
ance. Enteroptotic  patients,  as  a  rule,  look  pale  and  give 
the  impression  of  being  ill.  Their  spirits  are  usually  de- 
pressed. Characteristic  alterations  of  the  thorax  belong  also 
to  the  habitus  enteroptoticus :  the  thorax  is  long  and  narrow, 
and  the  shoulders  slant  downward.  The  epigastric  angle 
is  markedly  acute.  The  intercostal  spaces  are  sunken  and 
the  abdominal  walls  are  thin  and  flaccid.  The  distance 
between  the  umbilicus  and  the  ensiform  cartilage  is  greater 
than  in  a  normal  person.  The  epigastric  region  is  sunken 
when  the  patient  stands  erect.  The  abdomen,  however, 
below  the  navel  protrudes  in  consequence  of  the  weight  of 
the  descended  abdominal  viscera  (Fig.  24).  There  are 
frequently  found  broad  spaces  between  the  recti  muscles. 
During  respiration  the  lesser  curvature  of  the  stomach  will 
be  discerned  at  times  and  may  be  outlined  beneath  the  thin 
abdominal  wall.  A  special  feature  of  the  habitus  entero- 
ptoticus, according  to  Stiller,  is  a  movable  tenth  rib,  which 
is  shortened  and  freelj^  displaced  in  consequence  of  the 
absence  of  the  cartilaginous  attachment.  This  fluctu- 
ating rib,  known  as  Stiller' s  sign,  is  present  in  about  70 
to  80  per  cent,  of  cases  of  enteroptosis.  Many  writers, 
however,  consider  the  presence  or  absence  of  this  sign  of 
doubtful  diagnostic  value.  In  female  patients  it  is  possible 
at  times  to  palpate  the  abdominal  aorta  and  to  ascertain 
strong  pulsation  on  but  slight  pressure.  Stiller  considers  the 
ease  with  which  the  abdominal  aorta  ma}^  be  palpated  as 
a  sign  of  neurasthenia;  the  condition,  he  says,  is  due  to  a 
dilatation  or  paralysis  of  the  vessel  wall  brought  about  by 
reflex  causes.  The  celiac  plexus,  which  is  located  on  the 
anterior  surface  of  the  abdominal  aorta  in  the  epigastric 
region,  is  not  infrequently  very  sensible  to  pressure;  this 
condition  is  also  considered  suggestive  of  neurasthenia. 

Diagnosis.  —  Gastroptosis  is  recognizable  by  means  of 
inflation  of  the  stomach,  auscultatory  percussion  (Bene- 
dict), gastrodiaphany,  and  tiio  .r-rays.  Three  degrees  of 
gastroptosis  are  noted: 


NEPIIROPTOSTS  225 

1.  The  greater  curvature  is  situated  wholly  above  the 
umbilicus. 

2.  The  greater  curvature  is  situated  below  the  umbilicus 
with  the  lesser  curvature  above  it. 

3.  The  lesser  curvature  is  situated  below  the  level  of  the 
umbilicus. 

Hyperacidity  is  found  more  frequently  in  ptotic  stomachs 
than  is  subacidity  or  achylia. 

Ptosis  of  the  intestine  may  be  recognized  by  means  of 
auscultatory  percussion,  inflation  through  the  rectum,  or  the 
x-rays.  It  is,  as  a  rule,  associated  with  chronic  constipa- 
tion, which  is  due  in  large  measure  to  deficiency  in  the  tone 
of  the  abdominal  muscles.  Membranous  enteritis  is  occa- 
sionally present. 

Nephroptosis. — Displacement  of  the  kidneys  is  frequently 
found  in  enteroptosis — is  often,  indeed,  a  pathognomonic 
sign.  The  right  kidney  is  usually  the  one  affected.  The 
terms  movable  kidney,  dislocated  kidney,  wandering  kid- 
ney, floating  kidney,  prolapsed  kidney,  and  nephroptosis 
have  been  applied  to  a  variety  of  renal  displacements. 
Movable  kidney  is  said  to  be  five  or  six  times  more  fre- 
quent in  women  than  in  men.  Both  kidneys  movable  is  a 
condition  observed  almost  exclusively  in  women.  Inasmuch 
as  movable  kidney  implies  enteroptosis,  it  is  of  the  utmost 
importance  to  diagnosticate  the  condition.  The  diagnosis 
is  always  made  by  palpation.  The  correctness  of  the  result 
depends,  of  course,  on  the  degree  of  technical  skill  applied 
in  manipulation.  Every  physician  can  acquire  the  art  of 
palpation  by  careful  study  and  practice.  One  hand  is  placed 
on  the  back,  over  the  lumbar  region,  and  the  other  on  the 
abdomen;  bimanual  palpation  is  always  necessary.  The  cloth- 
ing should  be  removed  and  the  palpating  hands  brought  in 
direct  contact  with  the  skin.  The  abdomen  of  the  patient 
should  be  relaxed  as  completely  as  possible  before  the  exam- 
ination. The  hands  of  the  physician  should  be  placed  flat,  one 
on  the  back  and  one  on  the  abdominal  wall.  Severe  press- 
ure with  the  fingers  should  be  avoided.  It  is  best  to  begin 
softly,  allowing  the  pressure  to  become  gradually  greater. 
15 


226      ALTERATIONS  IN  POSITION    OF  ABDOMINAL   ORGANS 

The  palpating  hands  should  be  warm,  smce  cold  hands  cause 
contraction  of  the  abdominal  muscles  and  prevent  deep 
manipulation.  In  eases  where  the  tension  of  the  abdominal 
walls  is  too  great,  chloroform  narcosis  may  be  employed. 
This  is,  however,  rarely  necessary.  The  physician  may 
often  feel  the  kidney  slide  from  under  his  hands;  its  smooth 
surface  and  distinct  outline  are  very  characteristic.  In  pal- 
pating for  movable  kidney  the  patient  is  placed  in  three 
different  positions: 

1.  Standing  while  the  manipulator  sits  on  a  chair. 

2.  Lying  on  the  back  while  the  manipulator  sits  on  the 
edge  of  the  couch. 

3.  Lying  on  either  side,  according  to  which  kidney  is  being 
palpated,  while  the  manipulator  sits. 

First  position  (Fig.  25).  This  is  the  most  important 
position  for  palpating  a  movable  kidney,  since  it  per- 
mits the  maximum  displacement,  and  the  kidney  is  there- 
fore easily  felt.  Begin  by  superficial  pressure,  and  later 
use  deeper  manipulation.  Superficial  pressure  reveals  the 
resistance  in  the  abdomen  while  the  abdominal  muscles 
support  the  viscera,  and  the  hands  soon  differentiate 
between  the  natural  and  the  artificial  support  of  these 
muscles.  Deep  palpation  in  this  position  is  of  great  impor- 
tance, since  frequently  the  kidney  can  be  held  in  the  hand. 
With  one  hand  on  the  lumbar  region  the  whole  abdomen 
must  be  explored  with  the  other,  as  a  movable  kidney  may 
be  displaced  anywhere  from  its  normal  position,  even  as 
low  as  the  symphysis  pubis.  The  pecuUar  shape  of  the 
kidney,  its  smooth  characteristic  feel,  and  the  way  it  slips 
from  the  hand  under  the  ribs  will  make  it  easily  recognizable. 

When  a  kidney  is  in  normal  position  it  moves  slightly 
during  respiration.  A  normally  located  kidney  cannot  be 
palpated.  When  one-third  of  the  kidney  can  be  palpated 
the  condition  is  spoken  of  as  displacement  of  the  first  degree ; 
when  one-half  is  palpable,  displacement  of  the  second  degree ; 
when  the  whole  kidney  is  palpable,  displacement  of  the  third 
degree.  The  same  procedure  sliould  \)e  followed  out  in 
palpating  the  kidney  on  either  side.     On  account  of  their 


NEPHROPTOSIS 


227 


close  attachment  to  the  diaphragm,  the  Hver  and  gall- 
bladder move  during  respiration.  Care  should  be  exercised 
lest  they  be  mistaken  for  the  kidney. 


Fu;.  25 


First  position  for  palpating  movable  kidney. 

Second  position  (Fig.  26).  In  this  position  the  patient  lies 
on  his  back,  with  the  shoulders  raised  and  the  legs  slightly 
flexed.  One  hand  of  the  physician  is  placed  on  the  lumbar 
region  and  the  other  flat  on  the  abdomen,  below  the  costal 
margin  along  the  outer  border  of  the  rectus  muscle.  The 
patient  should  be  instructed  to  take  a  deep,  slow  inspiration, 
when  the  kidney,  if  movable,  may  be  felt  between  the  hands. 
The  kidney  naturally  drops  back  to  its  normal  position  when 
the  patient  lies  on  his  back,  for  which  reason  it  is  wise  to 
resort  to  other  positions  in  order  to  confirm  the  diagnosis. 


228     ALTERATIONS  IN  POSITION  OF    ABDOMINAL    ORGANS 

Usually  mobility  of  the  third  degree  is  best  made  out  with 
the  patieut  in  this  position. 

Third  position  (Fig.  27).  The  patient  should  lie  upon 
the  side  opposite  to  that  to  be  explored.  The  shoulders 
should  be  thrown  forward  and  the  thighs  shghtly  flexed. 

Fig.  26 


Second  position  for  palpating  movable  kidney. 
Fig.  27 


'''iiiii:iiiiniiiiiiiiiiiiiiiiii!iii!'-iii!iiiiiiiiiiiiiiiiiiiiiiiiiiii)iiin:iiiiii)ii))iiiiiiii)ii':" 


Third  i)ositioii  for  palpating  movable  Uidncy. 

The  physician  should  sit  on  the  edge  of  the  couch.  One 
hand  over  the  lumbar  region  and  the  other  over  the  abdomen 
will  bring  the  kidney  between  the  two  hands.  To  bring  it 
lower,  should  it  be  movable,  the  patient  is  instructed  to 
take  a  deep  inspiration,  when  the  diaphragm  will  force  it 
downward;  then  during  expiration  it  can  l)e  held  firmly 
between  the  hands.     The  slightest  relaxation  of  the  hand 


TREATMENT  OF  ENTEROPTOSIS  229 

will  permit  the  kidney  to  slip  away  from  between  the  fingers, 
which  is  characteristic  of  no  other  organ. 

Hepatoplosis. — Hepatoptosis,  dislocation  of  the  liver,  is 
of  frequent  occurrence  (Einhorni),  and  when  overlooked 
may  give  rise  to  diagnostic  error.  Landau  believes  that 
hepatoptosis  originates  from  the  same  cause  as  nephroptosis. 
Glenard  found  in  two-thirds  of  his  cases  of  hepatoptosis 
that  nephroptosis  was  also  present.  Hepatoptosis  with 
hepatic  colic  is  frequently  mistaken  for  cholelithiasis. 

Abnormal  positions  of  the  spleen  are  rarely  found. 

Prognosis. — The  prognosis  for  permanent  replacement  of 
the  displaced  organs  is,  as  a  rule,  not  good.  A  ptotic  stomach 
remains  so.  The  distressing  symptoms  accompanying  the 
condition  may,  however,  be  entirely  removed  or  greatly 
ameliorated  so  as  to  permit  patients  with  congenital  habitus 
enteroptoticus  to  pass  the  remainder  of  their  lives  in  com- 
parative comfort. 

Prophylaxis. — -Prophylaxis,  so  far  as  the  mechanical  causes 
of  enteroptosis  are  concerned,  consists  in  keeping  patients 
in  bed  for  a  longer  time  after  childbirth,  reinforcing  the 
abdominal  muscles  by  abdominal  bandages,  and  strengthen- 
ing the  muscles  by  massage.  By  these  measures  much  of  the 
muscular  relaxation  of  the  abdominal  wall  following  child- 
birth may  be  avoided.  Properly  fitting  corsets  are  a  valuable 
prophylactic  agency.  The  habitus  enteroptoticus  may  some- 
times be  recognized  in  young  subjects  by  their  peculiar 
physique  and  weak  stomach.  In  such  subjects,  marked 
departure  from  the  normal  may  be  retarded  by  suitable 
preventive  treatment  in  spite  of  the  existing  predisposition. 

Treatment. — The  treatment  of  gastroptosis  and  enteroptosis 
should  be  directed  toward  improvement  of  the  general 
nutrition,  in  order  to  counteract  the  neurasthenia  and  to 
strengthen  the  muscles  of  the  abdominal  walls. 

Diet. — Patients  who  are  poorly  nourished  must  be  well 
fed.  The  diet  should  be  as  nutritious  as  possible;  it  should 
contain  a  large  proportion  of  fat.  Milk,  cream,  and  butter 
are  among  the  most  suitable  articles  of  food  for  this  con- 

1  Floating  Liver  and  its  Clinical  Significance,  Medical  Record,  September  16, 

1899. 


230     ALTERATIONS  IN  POSITION    OF  ABDOMINAL    ORGANS 

dition.  The  nutrition  must  be  governed  almost  entirely 
by  the  requirements  of  the  individual  case.  The  motor 
and  secretory  powers  of  the  stomach  should  always  be  con- 
sidered in  prescribing  diet. 

Sometimes  it  is  necessary  to  resort  to  "forced  feeding," 
by  which  we  mean  hypernutrition.  It  is  well,  however, 
before  attempting  systematic  hypernutrition,  to  ascertain 
the  actual  powers  of  assimilation  of  the  patient.  In  de- 
termining the  status  of  a  patient's  nutrition,  two  factors 
must  be  borne  in  mind — first,  the  condition  of  the  protoplasm 
(muscles  and  blood),  and  secondly,  the  amount  of  fat  present. 
The  protoplasm  is  estimated  from  the  muscular  mass.  A 
person  with  weak  muscles,  as  a  rule,  suffers  from  deficiency 
in  nutrition.  An  attempt  should  be  made  to  strengthen 
the  weak  muscles  of  these  patients  by  hypernutrition,  and 
thus  bring  about  an  improvement  in  the  quality  of  the  blood. 

Fat  should  constitute  18  to  20  per  cent,  of  the  total  body 
weight  of  the  adult  male,  and  25  to  28  per  cent,  of  the  weight 
of  the  female.  It  is  necessary,  then,  for  the  physician  to  esti- 
mate as  well  as  he  can  the  quantity  relation  between  adipose 
tissue  and  muscle.  In  certain  diseases  the  presence  of  what 
might  be  termed  an  excess  of  fat  is  not  an  undesirable 
feature,  while  in  other  ailments  it  is  desirable  that  the 
amount  of  fat  be  less  than  in  the  normal  individual.  In 
gastroptosis  and  neurasthenia  it  has  been  found  advisable 
to  keep  the  nutrition  up  to  the  highest  possible  point,  and 
that  patients  do  better  when  the  amount  of  adipose  tissue 
is  above  the  indicated  percentage  for  their  body  weight. 
In  pursuing  a  course  of  hyperalimentation  it  is  an  advantage 
to  know  the  quantity  of  nutriment  required  by  each  patient 
in  order  to  maintain  his  particular  body  weight.  The  fol- 
lowing values  have  been  calculated  for  this  purpose: 

,  Calories  per  kiloKniininc  hotly 

'J'lic  patioiit  requires  weight  for  the  twenty-four  liours. 

1.  When  kcpL  in  bed 30  to  35 

2.  When  confined  to  the  room 32  to  35 

3.  When  emploj'ed  ;il  hght  labor 35  to  40 

4.  When  i*nii)li)yed  at  niediuin  physical  labor  .  40  to  45 

5.  When  employed  at  hard  labor 45  to  50 


TREATMENT  OF  ENTEROPTOSIS  231 

A  diet  corresponding  to  the  above  table  is  designated  a 
"sustaining  diet."  Such  a  regimen,  it  will  be  seen,  will  vary- 
in  the  same  individual,  depending  upon  the  question  of  rest 
or  physical  activity. 

Before  beginning  the  so-called  hyperalimentation  cure  it 
is  necessary  to  ascertain  the  sustaining  diet  for  the  patient. 
This  may  be  easily  accomplished  by  referring  to  the  standard 
tables  of  food  substances,  which  give  the  exact  percentages  of 
protein,  fat,  and  carbohydrates  in  the  food,  with  the  calorific 
value  of  each.  It  should  be  remembered  that  one  gramme 
of  protein  furnishes  4.1  calories,  one  gramme  of  carbohy- 
drate 4.1  calories,  and  one  gramme  of  fat  9.3  calories. 

Atwater  has  given  much  attention  and  study  to  the  heat 
values  of  various  food  substances.  His  figures  are  somewhat 
lower  than  those  of  the  older  investigators.  According  to 
Atwater : 

1  Gm.  of  protein  fui-nishes  4  calories. 

1  Gm.  of  carbohydrate  furnishes  4  calories. 

1  Gm.  of  fat  furnishes  9  calories. 

The  calculation  of  the  food  value  of  dishes  complex  in 
composition  should  be  entered  upon  with  great  care.  An 
exact  knowledge  of  the  composition  and  food  value  of  soups 
and  farinaceous  foods  is  necessary  if  the  physician  is  to 
avoid  error  in  dietary  prescription.  When  it  is  desired  to 
ascertain  the  exact  condition  of  undernutrition  of  a  patient, 
the  food  should  be  carefully  weighed  and  estimated  in  calo- 
ries and  the  result  compared  with  the  sustaining  diet  of 
that  particular  patient.  Should  the  amount  of  food  ordin- 
arily ingested  by  the  patient  be  less  than  the  sustaining 
diet,  the  condition  is  one  of  undernutrition.  It  is  customary 
to  speak  of  slight  undernutrition  when  the  difference  be- 
tween the  sustaining  diet  and  the  actual  food  taken  by  the 
patient  amounts  to  20  per  cent. ;  of  medium  undernutrition 
when  the  difference  is  20  to  40  per  cent. ;  of  high  grade  under- 
nutrition when  the  difference  is  40  to  50  per  cent. 

Hyperalimentation. — Hyperalimentation  consists  in  the  inges- 
tion of  certain  quantities  of  nutritive  material  in  excess  of 


232     ALTER ATIOXS  IX  POSITIOX  OF    ABDOMIXAL    ORGAXS 

the  amount  of  the  sustaining  diet.  This  added  nutriment 
is  known  as  the  food  surplus.  "VMien  the  calorific  value  of  the 
sustaining  diet  is  thus  increased  to  the  extent  of  30  to  40 
per  cent,  the  h\'peraUmentation  is  designated  "medium." 

Von  Xoorden  has  calculated  the  probable  increase  in 
weight  during  a  course  of  hj-peralimentation  as  follows: 

Daily  increase  in  food.  Weekly  increase  in  weight. 

500  to    800  calories  jield 600  to  1000  Gm. 

800  to  1200  calories  yield 800  to  1200  Gm. 

1200  to  1800  calories  jield 1200  to  2000  Gm. 

It  has  been  demonstrated  that  the  essential  increa.se  in 
weight  is  not  obtained  by  hyperalimentation  alone.  Con- 
siderable quantities  of  nitrogen  in  combination  are  retained 
in  the  body.  It  is  estimated  that  there  is  a  retention  of 
from  1  to  3  Gm.  of  nitrogen  dming  a  medium  food  addition 
per  day.  According  to  von  Xoorden  the  retained  protein 
does  not  enter  into  the  formation  of  protoplasm  proper,  but 
is  deposited  in  the  cells  as  the  so-called  reser^-ed  protein. 
This  deposited  protein  does  not,  however,  possess  the  ^'irtue 
of  U\dng  protoplasm,  and  is,  therefore,  rapidly  lost  on  the 
cessation  of  the  food  cure.  The  muscle  tis.sue  under  certain 
favorable  conditions  is  capable  of  making  use  of  the  deposited 
reserved  protein  for  muscle  prohferation.  One  of  the  best 
means  for  increasing  the  amount  of  muscle  tissue  is  s\'s- 
tematic  muscular  exercise.  If  the  patient  can  be  persuaded 
to  take  regular  muscular  exercise  during  the  food  cure  a 
marked  increase  in  flesh  will  result. 

Of  the  total  number  of  calories  represented  in  the  added 
food  in  a  com-se  of  hj-pernutrition,  8  per  cent,  is  used  up  for 
purposes  of  digestion  and  assimilation;  about  4  per  cent,  is 
lost  in  the  feces;  and  10  per  cent,  is  stored  up  as  protein. 
The  remaining  78  per  cent,  is  assimilated  as  fat. 

It  has  been  demonstrated  that  muscular  activity  develops 
the  muscles.  This  would  seem  to  be  in  opposition  to  the 
food  cure  as  outlined  b}'  those  who  first  made  use  of  it. 
Weir  Mitchell  and  Playfair  insisted  upon  having  their 
patients  maintain  the  recumbent  position.     But  one's  cases 


TECHNIQUE  OF  NUTRITION  233 

must  be  differentiated.  Some  are  too  weak  for  exercise,  or 
the  condition  of  the  digestive  system  may  require  absolute 
quietude. 

It  is,  moreover,  advisable  that  every  patient  be  put  to  bed 
for  the  first  eight  days  at  least  when  undergoing  the  so-called 
food  cure.  This  will  accustom  him  to  the  regular  adminis- 
tration of  food  and  hkewise  reduce  the  combustion  pro- 
cesses to  the  lowest  possible  degree.  The  radiation  of  heat 
is  diminished  and  its  retention  favored  by  complete  rest. 
Many  writers,  however,  prefer  that  patients  should  undergo 
active  muscular  movement  as  soon  as  there  are  signs  of 
increase  in  weight  during  the  first  week.  The  slight  loss 
of  weight  which  may  result  from  this  muscular  exercise  is 
soon  compensated  by  the  marked  increase  in  appetite  which 
follows  the  bodily  activity.  In  selected  cases  von  Noorden 
prescribes  daily  gymnastics  of  one  hour,  beginning  with  the 
second  week  of  treatment.  During  the  third  week  such 
patients  climb  an  inclined  plane,  such  as  a  hill,  to  the  height 
of  250  meters,  and  in  certain  cases  the  exercise  prescribed 
consists  of  rowing  and  swimming.  The  muscular  exercise 
should  be  so  arranged  as  to  avoid  undue  fatigue.  The  con- 
dition of  a  patient  after  a  course  of  hyperalimentation  com- 
bined with  muscular  exercise  will  be  much  more  vigorous 
than  if  the  exercise  had  been  omitted. 

Technique  of  Nutrition. — The  diet  should  not  consist  of  pro- 
tein substances  alone.  Their  calorific  value  is  more  than 
offset  by  the  difficulty  with  which  they  are  assimilated. 
From  12  to  15  per  cent,  of  the  energy  afforded  by  a 
protein  diet  is  lost  in  digestion,  as  compared  with  the  8 
per  cent,  waste  from  a  mixed  diet.  Protein  increases  com- 
bustion. In  the  sustaining  diet  the  daily  quantity  of  pro- 
tein is  about  100  Gm.;  in  hyperalimentation  it  should  be 
between  100  and  120  Gm.  This  amount  of  protein  is  found 
in  the  ordinary  mixed  diet.  Protein  may  be  administered 
in  any  form,  such  as  the  lean  varieties  of  meat,  fish,  or 
fowl.  Fat  has  the  disadvantage,  as  compared  with  lean 
meat,  of  more  quickly  satisfying  the  appetite  or  exciting  a 
distaste  for  animal  food.     The  portion  of  meat  should  not 


234     ALTERATIONS  IN  POSITION  OF    ABDOMINAL    ORGANS 

be  SO  great  as  to  prevent  the  ingestion  of  other  nutriment. 
Nervous  patients  should  not  receive  too  much  meat;  for 
this  class  of  patients,  eggs  should  be  freely  prescribed,  as  well 
as  cheese  and  milk.  The  artificial  protein  preparations  are 
also  worthy  of  consideration  here.  Casein  preparations  are 
especially  useful  in  cases  where  the  amount  of  food  the 
patient  is  able  to  take  is  small.  Von  Noorden  prefers  those 
preparations  in  which  the  casein  is  soluble,  such  as  somatose 
and  a  preparation  of  easily  digestible  albumoses  made  from 
fish;  the  latter,  designated  '^riba, "  contains  95  per  cent, 
of  protein,  and  60  to  80  Gm.  may  be  administered  per  day. 
This  quantity  is  almost  entirely  absorbed. 

Fat,  as  akeady  intimated,  is  the  most  valuable  article  of 
diet  in  the  food  cure,  owing  to  its  ver}^  high  index  of  com- 
bustion. At  least  200  Gm.  per  day  should  be  tenta- 
tively prescribed.  Patients  often  consume  with  ease  as 
much  as  250  grammes  of  fat  during  the  twenty-four  hours. 
It  is  well  to  have  some  standards  to  the  quantity  of  fat  to 
be  consumed  daily  during  the  course  of  the  food  cure  or 
hyperalimentation.  Von  Noorden  suggests  the  following 
daily  regimen: 

200  Gm.    butter  =  160  Gm.  fat  =  1490  fat  calories. 

1  liter  of  milk  =     33  Gm.  fat  =    307  fat  calories. 

300  Gm.    cream  =    7.5  Gm.  fat  =     698  fat  calories. 

The  total  amount  of  calories  yielded  by  the  fat  in  this  diet 
is  2495.  Not  every  patient  is  able  to  partake  of  this  quantity 
of  fat.  Cream  in  such  large  amount  is  apt  to  produce  disturb- 
ances which  destroy  the  appetite.  It  is  possible,  neverthe- 
less, in  constructing  a  dietary  with  fat  as  a  fixed  basis,  to 
attain  a  high  calorific  value.  Fat  should  be  prescribed  either 
as  liquid  or  in  a  form  easily  reduced  to  liquid,  such  as  but- 
ter, milk,  yolk  of  egg,  rich  cheese,  and  chocolate.  The 
resourceful  chef  or  housekeeper  will  find  many  ways  in 
which  these  articles  may  be  worked  up  into  a  variety 
of  tasty  dishes.  Butter  may  be  taken  by  itself  or  may  be 
made  an  ingredient  of  gravies,  so  that  as  nuich  as  200 
grammes  per  day  may  be  easily  ingested.  The  calorific  value 
of  milk  may  be  increased  by  adding  cream.     Coffee,  tea, 


TECHNIQUE  OF  NUTRITION  235 

or  milk  soups  may  be  administered  with  milk,  according 
to  the  taste.  Kefir  and  Yoghurt  milk  are  also  useful. 
Milk  may  be  concentrated  by  boiling.  There  is  also  to  be 
obtained  milk  in  powdered  form  which  may  be  added  to 
the  food.  Some  clinicians,  in  cases  where  patients  show 
much  emaciation,  restrict  the  amount  of  protein  during 
the  first  few  days  of  hyperalimentation  and  administer 
instead  a  milk-cream  mixture  in  such  quantities  as  would 
be  equivalent  to  the  sustaining  diet.  When  the  patient 
gains  in  strength  the  proper  proportions  of  protein  and 
carbohydrates  may  be  added. 

Great  precaution  is  necessary  in  the  administration  of 
the  fat  diet  lest  patients  acquire  a  distaste  for  it.  In  order 
to  obtain  the  benefits  of  hyperalimentation  it  is  necessary 
that  large  quantities  of  fat  enter  into  the  dietary  and  that 
the  patient  continue  thereafter  to  be  a  large  consumer  of 
fat.  It  is  only  in  the  presence  of  active  infiammiation  in  the 
stomach  or  small  intestine  that  fat  can  possibly  produce 
any  deleterious  effect. 

The  carbohydrates,  owing  to  the  fact  that  they  permit 
of  rich  variety  in  food,  form  important  elements  in  the 
food  cure.  They  also  render  unnecessary  the  prescribing 
of  protein.  Carbohydrates  in  the  hyperalimentation  cure 
are  capable  of  being  absorbed  to  the  amount  of  180  grammes 
per  day.  Von  Noorden  increases  this  amount  to  300 
grammes  and  over  per  day.  Carbohydrate  foods  may  be 
used  as  vehicles  for  butter,  eggs,  or  milk.  The  carbohydrate 
carriers  usually  employed  are  wheat  bread,  biscuits,  zwie- 
back, milk  soups,  oatmeal,  cereals,  and  breakfast  foods. 
Thick  soups  are  best  taken  early  in  the  morning  and  during 
the  evening  meal  rather  than  at  noon,  owing  to  their  satiating 
qualities.  Von  Noorden  recommends  oatmeal  porridge,  or 
hominy  made  from  corn,  to  be  eaten  with  cream.  Vegetables 
such  as  potatoes  should  be  given  in  the  form  of  puree  with 
large  quantities  of  fat.  Many  patients  are  particularly  fond 
of  chocolate,  which  may  be  taken  with  or  without  cream. 
Sugar  and  fruit  juices  may  be  prescribed.  Von  Noorden 
favors  the  prescribing  of  unfermented  grape  juice,  which  is 
very  agreeable  to  the  patient.     The  malt  preparations,  such 


236     ALTERATIONS   IN   POSITION   OF  ABDOMINAL   ORGANS 

as  malt  extract,  are  acceptable  to  many  patients;  thej^  pos- 
sess some  carbohA'drate  value. 

Alcohol  is  considered  by  some  authorities  as  possessing 
food  value.  It  is,  however,  of  but  little  importance  as  an 
element  in  the  food  cure.  Undoubtedly  the  effect  of  alcohol 
upon  the  nervous  system  more  than  offsets  any  virtue  it 
may  possess  as  a  food,  ^lien  it  is  deemed  advisable  to 
use  alcohol,  not  more  than  fifty  cubic  centimeters  should 
be  given  a  day,  and  then  only  in  the  form  of  a  light  wine 
with  a  raw  egg.  Erb  recoromends  Vial's  tonic  wine,  which 
contains  meat  extractives  and  bitters,  in  the  dietarj^  treat- 
ment of  neurasthenic  patients. 

All  dietary  regulations  should  be  made  with  due  regard  to 
the  secretory  and  motor  conditions  of  the  stomach  according 
to  the  directions  laid  down  in  the  chapters  dealing  with 
secretory  and  motor  derangements.  Before  a  food  cure  is 
instituted  it  is  necessary  to  know  whether  achylia,  sub- 
acidity,  normal  acidity  or  hyperacidity  is  present,  and  also 
the  condition  of  gastric  motilitj^ 

Under  favorable  conditions  the  food  cure  maj^  be  carried 
on  at  the  home  of  the  patient.  Better  results,  however, 
are  obtained  when  patients  are  prevailed  upon  to  leave  their 
home  surroundings  and  enter  a  well-managed  hospital  or 
a  sanitarium  where  special  attention  is  given  to  the  diet- 
etic treatment  of  disease.  Those  who  require  the  food  cure 
suffer,  as  a  rule,  from  nervous  exhaustion  and  overwork, 
and  often  from  physical  and  mental  collapse.  They  should 
be  placed  in  a  well-conducted  institution,  preferably  in  the 
countiy,  as  far  removed  as  possible  from  the  conditions 
surrounding  their  daily  routine,  and  kept  there  for  a  consid- 
erable period.  Much  is  achieved  with  this  class  of  patients 
by  surrounding  them  with  salutary  mental  influences.  The 
mental  influence  which  the  phj'sician  may  be  able  to  exert 
over  his  patient  has  an  important  bearing  upon  the  success 
of  the  treatment.  An  endeavor  should  be  made  to  inspire 
the  patient  with  hope,  and  to  overcome  as  far  as  possible 
his  prejudices. 

Once  the  patient's  weight  begins  to  increase,  and  hope 
and  confidence  are  established,  there  are  usually  few  if  any 


TECHNIQUE  OF  FOOD  CURE  2H7 

serious  difficulties  to  overcome.  The  patient  should  be 
educated  to  the  nature  of  his  disease;  he  should  understand 
that  improvement  will  be  gradual  and  will  depend  largelj^ 
upon  his  habits  of  living  and  his  mental  attitude  for  its 
permanency.  According  to  von  Noorden,  the  patient  must 
be  educated  to  become  a  big  eater  of  fat.  Often  within  a 
few  weeks  after  the  cessation  of  the  rest  cure,  patients 
relapse  into  their  former  condition,  owing  to  the  fact  that  they 
have  neglected  to  continue  the  cure  by  themselves.  This 
class  of  patients  thrive  best  when  in  personal  contact  with 
the  physician  in  a  sanitarium,  rather  than  at  home  and  at 
the  mercy  of  unreasonable  friends  and  relatives.  The  physi- 
cian in  the  hospital  or  sanitarium  should  have  the  assistance 
of  a  competent  chef,  capable  of  carrying  out  intelligently 
his  instructions.  ^^^  ^"^^  '-'' 

Technique  of  Food  Cure  (Boas).— In  carrying  out  the  so-called 
food  cure,  patients  should  be  confined  to  their  beds  for  a 
period  of  at  least  four  or  five  weeks,  during  which  time  a 
varied  diet  should  be  supplied,  nourishment  being  given 
every  two  or  three  hours.  Instead  of  the  large  quantities 
of  milk  that  were  at  one  time  prescribed,  patients  will  do 
better  if  given  one-half  to  one  liter  of  cream  daily  in  doses 
of  150  to  200  Cc.  The  diet  of  the  rest-cure  patient  should 
be  rich  in  carbohydrates  and  fat.  Constipation  may  often 
be  counteracted  by  adding  to  the  diet  such  articles  as 
honey,  marmalade,  preserves,  buttermilk,  sour  milk,  or  kefir. 
Boas  does  not  strongly  favor  massage  and  faradization  as 
adjuncts  to  the  rest  cure,  maintaining  that  any  effect  from 
these  agents  is  of  necessity  psychic. 

7  o'clock:  ^iKXfU\  ,     .,"- 

\  liter  Vigor  chocolate  in  cream.  ^—  \y^'^  ^  "'" 

3  to  4  zwieback  (2  rolls),  2e-te-30-GHi.  butter.  ^r\ 

9.30  o'clock: 

Cold  or  warm  meat,  eggs,  egg  foods,  light  or  white  bread  (perhaps 

Graham  bread),  26  Gm.  butter.  "-^  \W^' 
150  Gm.  cream.  ' 
Sweet  preserves  (stewed  fruit). 
Farinaceous  foods. 

1  to  2  glasses  of- eider,  grape  juice,  or  fruit  wine  (perhaps  also  some 
raw  fruit). 


238     ALTERATIONS  IN  POSITION  OF    ABDOMINAL    ORGANS 

12  o'clock:  Yj^^^     ^   W:;^, 

150  Gm.  cream.  3"      I  I 

2  or  3  biscuits  (crackers). 

2  o'clock: 

iJiter  soup.  ' 

Vegetables  and  potatoes  in  puree  form. 

Meat  and  fish. 

Salad. 

Stewed  fruits  (sweet). 

4.30  o'clock:  -"■:  ^77 

Coffee  or  tea  (150  Gm.)  with  cream.  "~  ' 

Zwieback,  cakes,  Graham  bread,  butter  C20  Gm.)  or  honey.  ^~ 

8  o'clock: 

Cold  or  warm  meat  or  fish. 

Eggs  or  egg  foods. 

Light  bread,  Graham  bread  (30  Gm.),  butter. 

Stewed  fruits.  kT^vA* 

2  glasses  of  fruit  wine  or  1  bottle  of  malt  beer. 

9.30  o'clock:  -rf     l  '    V 

^^     20e-€^m.  cream  wdth  2  or  3  crackers.     Lc»-vCL    VKUM] 

The  purpose  of  the  so-called  food  cure  is  not  to  render 
patients  corpulent.  The  increase  in  weight  should  be  made 
to  correspond  to  the  weight  of  the  person  in  a  condition  of 
health,  taking  into  consideration  his  size  and  hereditary 
constitution.  Proper  attention  throughout  the  food  cure 
should  be  paid  to  the  matter  of  increasing  muscular 
power.  The  need  is  apparent  for  systematic  muscular 
exercise.  Patients  should  be  permitted  a  certain  amount 
of  mental  activity,  such  as  reading,  which  keeps  them  from 
dwelling  upon  their  ailments.  Hydrotherapeutic  measures 
may  be  instituted  and  carried  out  in  conjunction  with  the 
food  cure;  they  should  be  limited,  however,  to  methods  of 
a  stimulating  and  invigorating  character,  ^'^on  Renvers 
recommends,  in  asthenic  conditions  of  the  heart  muscle, 
systematically  performed  respiratory  gymnastics,  to  be  car- 
ried out  several  times  a  day.  The  muscles  of  the  body  may 
be  stimulated  by  dry  rubbing  of  the  skin  with  rough  towels. 
The  anemic  condition  of  the  patient  is  often  overcome  during 
the  food  cure  by  the  muscular  and  res]iiratory  exercises. 
Arsenic  in  the  form  of  Fowler's  solution   ]){)ssesses  some 


TECHNIQUE  OF  FOOD  CURE  239 

virtue  as  a  hematinic.  Arsenic  has  been  found  to  have  an 
antihemolytic  effect.  Both  the  arsenite  and  the  arsenate  of 
sodium  defend  the  red  blood  corpuscles  from  the  action  of 
certain  hemolytic  agents.  Arsenic  is  indicated  in  anemic 
conditions  that  result  from  pathologic  derangement  of  the 
medullary  substance  of  the  bones.  In  genuine  chlorosis, 
iron  should  be  administered  hypodermically.  All  patients 
suffering  from  enteroptosis  recjuire  iron  in  some  form. 
They  cannot  take  it  internally,  owing  to  its  irritating  effect 
upon  the  gastric  mucous  membrane.  This  may  be  over- 
come by  hypodermic  medication.  Of  all  the  iron  prepara- 
tions, ferric  citrate  has  been  found  best  for  hj^^odermic 
use;  as  a  reconstructive  hematinic  it  is  probably  the 
best  form  of  the  metal.  Iron  supplies  the  deficiency  in 
hemoglobin.  The  iron  compounds  are  indicated  in  all 
cases  of  anemia.  Combined  with  arsenic,  iron  acts  as  an 
alterative,  and  the  compound  may  be  used  in  all  cases  of 
cachexia  and  in  all  anemias.  A  pill  made  up  of  iron,  arsenic, 
and  strychnine  is  particularly  valuable  in  the  treatment  of 
enteroptosis  and  neurasthenia.  Iron,  arsenic,  and  strychnine 
in  the  form  of  glycerophosphates  are  indicated  in  all  dis- 
turbances of  a  nervous  nature,  particularly  in  those  neuro- 
muscular cases  where  there  is  a  marked  deficiency  of  phos- 
phates. The  cacodylate  of  iron  is  particularly  valuable  in 
combating  the  graver  forms  of  anemia  which  are  found 
sometimes  associated  with  enteroptosis.  Owing  to  the  fact 
that  this  preparation  is  well  borne  by  the  kidneys,  it  can  be 
prescribed  in  all  cases  of  anemia  and  kidney  involvement. 

Of  the  various  forms  of  phosphorus,  lecithin  is  most 
easily  assimilated.  It  is  useful  in  neurasthenia  dependent 
upon  exhaustion,  as  well  as  in  other  neuroses.  In  malnu- 
trition, lecithin  exercises  a  stimulating  effect  upon  the  cell 
protoplasm. 

Of  all  methods  of  administering  drugs,  the  hypodermic  is 
giving  the  best  results.  Professors  Carnedi  and  ]\Iarchetti 
and  others  among  the  Italians  have  done  much  to  develop 
this  mode  of  administering  pharmacopeial  preparations. 
These   preparations   are   put  up    in  the   form   of    aseptic 


240     ALTERATIONS  IN  POSITION  OF    ABDOMINAL    ORGANS 

solutions  in  hermetically  sealed  glass  ampoules/  The  stem 
of  the  ampoule  in  which  the  dose  is  contained  is  broken  off, 
and  the  dose  drawn  up  into  the  syringe.  The  injections 
are  made  deep  into  the  gluteal  region;  it  is  necessary  that 
the  injections  be  intramuscular.  The  following  combina- 
tions can  be  used: 

Gramme. 

Iron  cacodylate 0.03 

Iron  citrate  (green) 0.05 

Sodium  arsenate 0.001 

Iron  citrate  (green) 0.05 

Iron  citrate  (green) 0.05 

Strychnine  sulphate 0.001 

Iron  citrate  (green) 0.05 

Arsenate  of  soda 0 .  001 

Strychnine  sulphate 0 .  0005 

Iron  citrate  (green) 0.05 

Sodium  glycerophosphate 0.05 

Sodium  arsenate 0.001 

Iron  citrate  (green) 0 .  05 

Sodium  glycerophosphate 0 .  05 

Strychnine  sulphate 0.001 

Iron  citrate 0.05 

Sodium  glycerophosphate 0 .  20 

Bisodium  met.  arsenate 0.10 

Strychnine  sulphate 0.001 

Iron  citrate 0.10 

Sodium  glycerophosphate 0.50 

Bisodium  met.  arsenate 0.10 

Strychnine  sulphate 0.001 

Iron  citrate .      .  0.05 

Sodium  glycerophosphate 0.20 

Bisodium  met.  arsenate 0.10 

Sodium  formate 0.15 

Strychnine  sulphate 0 .  001 

As  the  general  nutrition  of  the  patient  improves,  the 
stomach  and  intestine  will  likewise  become  tolerant  of  a 
greater  quantity  and  variety  of  food.  Patients  with  entero- 
ptosis  complicated  with  neurasthenia  should  be  considered 
cured  only  when  they  may  again  partake  of  a  normal  diet 
without  any  distressing  after-symptoms  and  when  the  work 
of  the  intestinal  tract  is  normally  performed.  To  accom- 
plish this  result  is  the  purpose  of  the  food  cure.     In  the 

'  By  Moltcni  iV-  Company,  of  Florence,  Ilaly;  imported  hy  L.  .V.  Seltzer,  of 
Detroit. 


TECHNIQUE  OF  FOOD  CURE  241 

treatment  of  enteroptotic  and  neurasthenic  patients  Strauss 
reports  favorable  results  from  the  following  alimentation: 

Breakfast:  Flour  soup  rich  in  butter;  porridge,  cocoa  with  milk-and-cream 

mixture,  egg,  and  some  buttered  rolls. 
Dinner:  Dishes  made  of  flour  and  eggs  and  cream. 

In  the  afternoon :  Crackers  with  milk-cream  mixture,  zwieback  and  butter . 
Supper:   Should  consist  of  the  rich  flour  soups  or  dishes  made  from  flour 

and  eggs,  with  a  beverage  of  tea  and  milk-cream  mixture. 
Before  going  to  bed  the  patient  is  permitted  a  glass  of  milk-cream  mixture. 
In  addition,  side  dishes  of  malt  extract  and  fruit  juices  may  be  permitted. 


Diel  (Z^aeg). 

Calories. 
8.  A.M.     h  Uter  of  milk,  with  tea, 
50  Gm.  white  bread, 
20  Gm.  butter, 
30  Gm.  honey 680 

10.00  A.M.     \  liter  kefir  (one  day  old), 
50  Gm.  Graham  bread, 
20  Gm.  butter   ....  .  .  .420 

12.30  noon  150  Gm.  meat  or  fish, 
250  Gm.  vegetables, 
50  Gm.  apple  sauce, 

1  omelet  from  two  eggs, 
10  Gm.  butter, 
10  Gm.  sugar. 
Fruit:  grapes,  oranges,  figs   ....  .      .       900 

4.00  P.M.     1  hter  milk. 

6.00  P.M.     I  Uter  milk  chocolate, 
50  Gm.  Graham  bread, 
20  Gm.  butter, 
Tablespoonful  of  honey  .  ...      1020 

8.00  P.M.      2  eggp, 

100  Gm.  meat,  fowl,  oj  fish, 
50  Gm.  preserves, 
100  Gm.  vegetables, 
50  Gm.  Graham  bread, 
20  Gm.  butter, 
20  Gm.  soft  cheese     ....  .      .  1190 

\  liter  milk. 

9.30  P.M.       \  Uter  kefir. 

Total 4210 

16 


242     ALTERATIONS  IN  POSITION  OF    ABDOMINAL    ORGANS 


Diet  Lift  (Boas), 

7.00  A.Ji.  J  liter  of  chocolate  with  cream,  3  to  4  zwieback  or  nisks, 
20  to  30  Gm.  butter. 

9.30  A.M.  Cold  or  warm  meat,  eggs,  egg  dishes,  white  bread,  20  Gm. 
butter,  1.50  Gm.  cream,  1  to  2  glasse.s  of  apple  or  some 
other  fruit  wine. 

12.00  M.       150  Gm.  cream,  2  to  3  biscuits. 

2.00  P.M.  I  liter  soup,  vegetables,  mashed  potatoes,  meat  or  fish,  salad, 
sweet  preserves. 

4.30  P.M.  Coflfee  or  tea  \\ith  cream  (1.50  Gm.),  zwieback,  biscuits,  butter 
(20  Gm.),  or  honey. 

8.00  P.M.  Cold  or  warm  meat  or  fish,  eggs,  egg  dishes,  white  bread, 
30  Gm.  butter,  preserves,  2  glasses  of  fruit  vrine. 

9.30  P.M.  Cream  with  2  to  3  biscuits. 


Exercise  and  Massage. — Phj'sical  exercises  perform  an  im- 
portant role  in  strengthening  the  abdominal  walls  while 
they  add  tone  to  the  musculature  of  the  gastro-intestinal 
tract. 

Massage  of  the  stomach  is  indicated  in  those  forms  of 
gastroptosis  in  which  there  is  no  pyloric  stenosis.  It  is  also 
indicated  in  atony  and  nervous  dj'spepsia.  The  reader  is 
referred  to  the  chapter  on  ^Massage  for  the  technique. 

^Massage  of  the  abdomen  and  intestine  is  recommended 
along  with  gastric  massage.  The  purpose  of  abdominal 
massage  is  to  strengthen  the  relaxed  abdominal  walls, 
stimulate  peristalsis,  and  improve  the  circulation  in  the 
abdominal  vessels  by  stimulation  of  the  sympathetic  ner- 
vous system.  The  technique  of  abdominal  massage  as 
performed  by  Hoffa  is  as  follows:  The  patient  should  be 
placed  on  a  firm  couch  or  table,  with  his  head  slightly 
elevated;  the  lower  extremities  are  flexed  at  the  hips  and 
knees.  The  physician  occupies  a  position  to  the  right  of 
the  patient.  Massage  should  be  commenced  very  gentlj^ 
especially  in  the  case  of  patients  on  whom  it  is  being  per- 
formed for  the  first  time,  in  order  to  prevent  rigiditj'  of  the 


PLATE  V 


FIG.    I 


Abdon-iinal  Massage,  First  Movement.    (Hoffa.) 


Abdominal  Massage,  Second  Movenient.     (Hoffa.) 


PLATE  V 


Abdominal  Massage,  Third  Movement.     (Hoffa.) 


EXERCISE  AND  MASSAGE  248 

abdominal  walls — which  renders  deep  massage  practically 
impossible.  Both  hands  should  be  laid  upon  the  abdomen 
and  slight  rotating  movements  made  (rotating  effleurage). 
Concentric  circles  should  be  made  in  the  direction  of  the 
hands  of  the  clock.  The  movements  should  be  begun 
at  the  symphysis,  proceeding  upward,  and  then  over  the 
entire  abdomen  (Plate  V,  Fig.  1).  These  movements 
are  designed  to  overcome  the  tension  of  the  abdominal 
walls;  in  particularly  stout  patients  the  circular  movements 
may  be  followed  by  kneading  of  the  abdominal  walls  (petris- 
sage). Deep  kneading  of  the  intestine  should  follow,  the 
purpose  being  to  stimulate  intestinal  peristalsis  and  thereby 
loosen  impacted  fecal  matter.  Both  hands  should  grasp 
in  the  direction  of  the  intestine  through  the  abdominal 
walls;  zigzag  movements  to  and  fro  are  to  be  made 
(Plate  V,  Fig.  2). 

Deep  petrissage  should  involve  the  whole  abdomen, 
affecting  particularly  the  median  portion  of  the  intestinal 
tract,  namely  the  ileum.  The  operator  should  next  proceed 
toward  the  large  intestine.  The  movements  are  made 
first  by  the  right  hand,  which  is  dorsally  flexed  and  placed 
in  the  right  pubic  fossa  at  the  beginning  of  the  ascending 
colon  (Plate  VI).  Pressure  is  made  as  deeply  as  possible, 
and  in  order  to  augment  it  the  points  of  the  fingers  of  the 
left  hand  should  be  pressed  upon  those  of  the  right.  The 
large  intestine  should  be  constantly  subjected  to  deep 
pressure;  the  points  of  the  fingers  are  pushed  at  first 
upward,  then  transversely  below  the  arch  of  the  ribs 
toward  the  left  side,  and  finally  downward  so  that  the 
stroke  penetrates  deeply  into  the  left  iliac  fossa.  The 
pressure  then  ceases  and  the  hands  glide  over  the  blad- 
der back  to  the  right  iliac  fossa,  from  which  point  the 
stroking  of  the  large  intestine  should  be  repeated  several 
times.  A  few  rotating  efileurage  movements  of  a  soothing 
nature  should  be  performed.  Then  should  follow  kneading 
of  the  large  intestine  (rotating  petrissage).  With  the  left 
hand  superimposed  on  the  right,  the  fingers  of  both  hands 
should  push  with  a  rotating  motion  into  the  cecal  region, 


244     ALTERATIOXS  IN  POSITION  OF    ABDOMINAL  ORGANS 

with  the  finger  ends  pointing  toward  the  chest.  The  initial 
pressure  and  movements  should  be  light  and  rotating,  to 
be  gradually  increased  until  the  whole  course  of  the  large 
intestine  is  massaged  with  this  rotating  pressure. 

The  muscles  of  the  intestinal  tract  should  then  be  sub- 
jected to  shght  stimulating  ''  tapotement."  WTiile  executing 
these  latter  movements  the  hands  should  be  held  so  that  the 
thumb  is  approximated  to  the  index  finger  and  the  other 
fingers  are  slightly  flexed  at  the  metacarpophalangeal 
joints.  With  the  hands  in  this  position  the  abdomen  should 
be  shghtly  tapped  in  all  directions.  Alore  \dgorous  tapote- 
ment may  be  performed  with  the  dorsal  surface  of  the  flexed 
fingers,  the  middle  finger  being  elevated  shghtly  above  the 
others.  This  procedure  may  be  advantageously  followed 
by  shaking  motions  with  the  right  hand  placed  flat  on  the 
central  part  of  the  abdomen,  the  fingers  of  the  operator 
being  spread  widely  apart. 

The  sympathetic  nerve  plexuses  may  be  reached  by  vibra- 
tion. In  order  to  get  at  the  celiac  plexus  the  ends  of  the 
fingers  are  placed  lightly  upon  the  abdomen  midway  between 
the  umbilicus  and  the  ensiform  cartilage;  gi'adual  pressure 
should  then  be  exerted,  penetrating  more  deeply  with  each 
respiratory  retraction  of  the  diaphragm  until  the  spinal 
column  is  reached,  when  motions  of  a  vibrating  or  trembling 
nature  should  be  executed. 

The  splanchnic  plexus  is  reached  in  the  same  manner, 
except  that  the  straight  fingers  should  penetrate  toward 
the  spinal  column  midway  between  the  umbilicus  and  the 
symphysis. 

The  abdominal  massage  ma^^  be  followed  with  advan- 
tage by  a  general  vibration  of  the  abdomen,  given  gently  bj- 
means  of  an  electric  vibratory  apparatus. 

The  stomach,  bladder  and  rectum  should  be  emptied 
before  massage  of  the  abdomen  is  begun. 

In  addition  to  the  massage  the  patient  should  perform 
gymnastic  exercises  to  invigorate  the  abdominal  wall.  He 
may  assume  a  squatting  posture,  with  the  knees  flexed  until 


ELECTROTHERAPEUTICS  245 

the  thigh  rests  on  the  calf;  or  he  may  be  instructed  to  raise 
himself  into  the  sitting  posture  when  lying  flat  upon  the 
back.  Zabludowski  has  the  patient  lie  at  full  length  in 
order  to  counteract  atony  of  the  gastro-intestinal  tract  by 
a  better  circulation  of  the  blood. 

Massage  is  indicated  in  floating  kidney,  the  purpose  being 
to  tone  up  the  abdominal  wall.  It  should  be  practiced 
as  already  described  and  be  followed  by  the  left  hand 
pressing  the  soft  parts  from  behind  up,  the  right  hand  in 
the  meantime  performing  replacement  movements  upon 
the  kidney. 

The  massage  process  in  gastroenteroptosis  must  be  varied 
according  to  the  anatomic  relation  of  the  parts.  Gastric 
massage  may  immediately  precede  abdominal.  "V^Hien  these 
movements  cannot  be  conveniently  performed  daily  by  the 
physician,  the  patients  may  practice  on  themselves  by 
means  of  a  cannon  ball,  which  should  not  weigh  more  than 
from  three  to  five  pounds.  A  sphere  of  wood  weighted 
with  shot  answers  the  purpose  in  auto-massage  very  nicely. 

Electrotherapeutics. — Gastroptosis  and  enteroptosis  are  some- 
times improved  under  a  course  of  electrotherapeutics.  In 
relaxation  of  the  abdominal  muscles  and  intestinal  torpor, 
faradization  is  indicated.  Two  large  plate  electrodes  four 
to  six  inches  square  are  applied  to  the  two  sides  of  the  ab- 
domen, or,  if  desired,  over  the  epigastric  and  hypogastric 
regions.  The  faradic  current  should  be  turned  on  slowly 
and  its  strength  increased  gradually  so  that  distinct  con- 
traction of  the  abdominal  muscles  becomes  apparent.  One 
plate  electrode  may  be  placed  over  the  region  of  the 
stomach  and  the  other  utilized  as  an  electric  roller  to  follow 
the  course  of  the  large  intestine  under  deep  pressure.  The 
galvanic  current  is  indicated  in  cases  characterized  by  ab- 
dominal pains  of  neurotic  origin.  As  much  as  thirty  milli- 
amperes  may  be  used,  with  one  electrode  over  the  stomach 
and  the  other  over  the  bladder.  In  torpidity  or  sluggish- 
ness of  the  bowels,  intrarectal  faradization  has  proved  to  be 
an  effective  therapeutic  agent. 


246      ALTER ATIOXS  IX  POSITION  OF  ABDOMINAL  ORGANS 

Hydrotherapeutics. — The  hydrotherapeutic  procedures  suit- 
able to  this  class  of  cases,  namely,  gastroptosis  or  entero- 
ptosis  complicated  with  neurasthenia,  consist  of  the  appli- 
cation of  cold  water,  half  baths,  Scotch  douches  on  the 
abdomen  and  stomach,  cold  friction  rubbing  and  slapping, 
and  cold  full  packs.  The  prolongation  and  intensity  of 
these  hydrotherapeutic  measures  must  be  varied  to  suit  the 
requirements  of  the  case. 

Nervous  debility  wdll  at  times  be  greatly  benefited  bj' 
sojourn  in  the  country,  at  the  seashore,  or  other  climatic 
health  resort. 

Mechanical  Treatment  of  Enteroptosis. — The  mechanical  thera- 
peutics consist  principally  in  the  bandaging  of  the  abdomen 
with  a  view  to  suppl^'ing  support  to  the  relaxed  abdominal 
wall  and  to  fixing  the  displaced  viscera;  especially  is  this 
treatment  indicated  in  enteroptosis  due  to  mechanical 
causes.  In  constitutional  enteroptosis  the  mechanical  treat- 
ment, so  called,  is  palliative  merely,  but  of  very  great 
value.  It  acts  beneficially  by  ameliorating  the  symptoms 
which  arise  from  tension  or  stretching  of  the  abdominal 
organs.  The  mechanical  support  consists  of  abdominal 
bandages  or  abdominal  corsets. 

Apparatus  for  this  purpose  is  available  in  great  variety, 
but  everything  has  its  peculiar  defects,  such  as  uncomfort- 
able perineal  straps  or  badly  fitting  pads,  which  occasion 
patients  no  small  degree  of  annoyance.  It  is  a  very  difficult 
matter  to  find  well-fitting  "ready-made"  corsets  or  abdomi- 
nal bands.  Among  the  best  known  and  most  suitable  ap- 
pUances  for  the  treatment  of  enteroptosis  and  gastroptosis 
are  the  abdominal  bandage  of  Glenard  and  Teufel,  the  girdle 
of  Hera  for  pendulous  abdomen,  and  the  abdominal  bandage 
of  Burger  recommended  by  Riegol.  The  last  i)ossesses  great 
adaptability;  it  is  light  in  weight  and  leaves  the  hips  unen- 
cumbered. It  consists  of  a  closely  fitting  body  plate,  and 
back  holders  made  of  celluloid,  with  removable  and  adjust- 
able eyelets. 

In  order  to  ascertain  whether  a  band  is  indicated  in  a 
given  case,  the  so-called  "belt  sign"  of  (Jlenard  should  be 


PLATE  VII 


Author's  Abdominal   Bandage. 


PLATE  VIII 


Author's  Abdominal   Bandage,  Showing  Con- 
struction in   Detail. 


MECHANICAL   TREATMENT 


247 


employed.  The  physician,  standing  behind  the  patient, 
passes  his  arms  on  either  side  and  places  both  hands  on  the 
lower  abdominal  wall.  With  the  hands  in  this  position  the 
abdominal  mass  just  above  the  pubes  can  be  easily  raised. 
The  physician  should  then  suddenly  remove  his  hands,  per- 
mitting the  abdominal  mass  to  fall;  if  then  the  patient's 
distressing  symptoms,  relieved  by  the  temporary  support, 
return,  the  indication  is  positive  for  the  use  of  an  abdominal 


Fig.  28 


Glenard's  "belt  sign"  (^preuve  de  la  sangle). 

band  or  support.  Glenard  calls  this  phenomenon  '^epreuve 
de  la  sangle"  (Fig.  28).  Should  the  patient  experience  no 
relief  when  the  abdomen  is  lifted,  and  feel  if  anything  better 
when  it  is  permitted  to  assume  its  old  position,  the  band 
will  not  give  good  results. 

The  author's  bandage,'  as  presented  before  the  American 
Medical  Association  at  Philadelphia,  June,  1897,  has  been 
used  by  him  with  success  in  selected  cases  (Plate  VII). 
It  has  in  no  way  been  modified  from  the  form  introduced 
to  the   profession,  and  has  proved  eminently  satisfactory 


1  The  bandage  devised  by  the  author  is  manufactured  by  G.  J.  De  Garmo, 
108  East  23d  Street,  New  Yorlc. 


248     ALTERATIONS   IN   POSITION  OF  ABDOMINAL    ORGANS 

(Plate  VIII).  It  is  supplied  with  a  truss  which  is  fitted 
to  the  band  encircling  the  body  below  the  crest  of  the 
ihum  and  above  the  trochanter  (Plate  IX).  This  bandage 
exerts  a  pressure  upon  the  hypogastrium  from  below  up- 
ward, raising  the  intestines,  which  in  turn  act  as  a  cushion  for 
the  stomach.  In  this  way  the  tension  upon  the  abdominal 
organs  is  reUeved  (Plate  X,  Fig.  1).  The  bandage  should 
be  adjusted  properly  in  order  to  prevent  slipping  up  at  the 
back,  or  no  benefit  will  be  derived  from  its  use  (Plate  X, 
Fig.  2).  \Anien  the  bandage  is  properly  applied  it  affords 
abdominal  support  and  at  the  same  time  leaves  the  ribs  and 
diaphragm  free  from  all  compression  and  the  respiratory 
movements  free.  There  is  no  pressure  over  the  solar  plexus. 
The  wearing  of  the  author's  abdominal  bandage  tends  to 
develop  in  patients  a  deep,  broad,  prominent  lower  chest 
and  epigastrium,  which  is  the  condition  found  in  well- 
developed  normal  individuals. 

My  bandage  has  been  found  valuable  in  the  treatment  of 
abdominal  pain  due  to  a  loose  sacro-iliac  joint.  This  pain, 
as  originally  described  by  Goldthwait,^  is  apt  to  be  associated 
with  more  or  less  severe  headache,  generally  on  one  side  over 
the  sacro-ihac  joint.  It  sometimes  extends  through  to  the 
front  of  the  joint,  where  it  is  most  apt  to  be  mistaken  for 
an  affection  of  some  pelvic  organ.  The  existence  of  this 
condition  is,  as  a  rule,  indicated  by  the  fact  that  the  affected 
leg  is  shortened,  and  that  pain  results  when  the  leg  is  rotated, 
forced  strongly,  or  pulled  outward.  ]\Iost  of  these  patients 
are  relieved  by  the  application  of  my  bandage. 

Einhorn's  bandage-  is  perforated  over  the  iliac  crests  in 
order  to  prevent  undue  pressure  on  these  parts.  J.  Madison 
Taylor"*  describes  a  belt  devised  by  Alorris  Longstreth  (Figs. 
29  and  30),  who  has  used  it  for  over  a  quarter  of  a  century. 
This  belt  may  be  used  alone  or  attached  to  any  well-fitting 
corset.  Taylor's  experience  with  this  belt  has  been  most 
gratifying.     The  belt  consists  of  a  broad   band  of  stout 

'  Ro.ston  Medical  and  Surgical  Journal,  11)0"),  p.  .'M\. 

'  Remarks  on  Entcroptosis,  Medical  Record,  April  13,  1901. 

'  New  York  Medical  Journal,  May  11,  l'.)07. 


PLATE   IX 


Abdoniinal   Bandage  in   Position. 


PLATE  X 


Abdominal   Bandage 
Properly  Adjusted. 


Abdominal  Bandage  Im- 
properly Adjusted. 


MECHANICAL  TREATMENT 


249 


webbing,  which  may  be  attached  to  the  lower  edge  of  a  corset 
and  carefully  fitted  to  the  individual,  coming  well  down  over 
the  external  trochanters.  Posteriorly  it  is  cut  vertically  and 
the  edges  joined  by  four  straps  with  buckles,  so  that  the 
belt  may  be  adjusted  to  fit  the  needs  of  the  case;  in  front 
it  is  caught  by  a  series  of  broad  hooks  which  are  joined  or 
disengaged  as  the  corset  is  put  on  or  off. 


Fig.  29 


Fig.  30 


Longstreth's  belt  attached  to  corset- 
side  view. 


Longstreth's  belt  attached  to  corset- 
back  view. 


Byron  Robinson  advocated  a  rubber  air-pad  placed  inside 
an  elastic  or  non-elastic  abdominal  bandage. 

Other  bandages  have  been  devised  by  Boas,  Ewald, 
Witthauer,  Spivak,  and  Vermehren. 

An  appliance  very  much  in  vogue  is  an  adhesive  plaster 
bandage  by  Rose/  of  New  York.  It  consists  of  zinc  oxide 
moleskin  adhesive  plaster  one  yard  long  and  eight  inches 


Medical  Fortnightly,  February,  1909. 


250      ALTERATIONS  IN  POSITION  OF  ABDOMINAL    ORGANS 

wide.  From  this  a  pattern  is  cut  as  shown  in  Fig.  31.  The 
writer  is  in  the  habit  of  placing  the  patient  in  the  Trendelen- 
burg position  in  order  to  apply  this  plaster  bandage.  All 
hairy  portions  of  the  body  covered  by  the  bandage  should 
be  shaved  to  facihtate  removal.  The  plaster  should  not 
include  the  crest  of  the  ilium,  but  should  run  closely  along 
and  above  it.  The  epigastric  region  remains  uncovered 
(Fig.  32).  Most  patients  find  this  bandage  fairly  comfort- 
able.    Unfortunately,  it  is  impossible  to  keep  it  in  place 

Fig.  31 


Pattern  for  adhesive  belt.      (Rose.) 

longer  than  three  to  four  weeks,  owing  to  the  fact  that  the 
plaster  loses  its  adhesiveness.  This  support  may  be  re- 
moved easily  by  applying  benzin  or  ether. 

The  removal  of  adhesive  plaster  from  the  skin  of  a  patient 
is  accompanied  by  considerable  pain  and  discomfort. 
Beardsleyi  found  that  oil  of  wintergrcen  applied  to  ad- 
hesive plaster  removed  completely  the  adhesive  elements 
in  a  very  short  time.  It  is  not  necessary  to  use  more  than 
a  small  amount  of  the  oil,  which  is  applied  directly  to  the 

'  An  Ea.sy  and  Painless  Method  of  Removing  Adhesive  Plaster,  Journal 
of  the  American  Medical  Association,  January  2S,  1911,  ji.  203. 


MECHANICAL   TREATMENT 
Fig    32 


251 


Adhesive  plaster  bult  adjusted.      (Rose.) 


FtG.  33 


FiQ    34 


Adhesive  plaster  bandage — tront  view. 
(Eisner.) 


Adiiesive  plaster  bandage — bacli  view. 
(Eisner.) 


252      ALTERATIONS  IN  POSITION  OF  ABDOMINAL  ORGANS 

plaster  and  easily  spreads  itself  throughout  the  adhesive 
material.     When  extensive  areas  of  plaster  are  to  be  re- 


FiG.  35 


Adhesive  bandage — front  view.      (Helfenberg  ) 
Fia    30 


Adhesive  bandage — back  view.      (Helfenberg. 


MECHANICAL  TREATMENT 


253 


moved  the  application  of  an  ointment  of  adeps  lana?  hydrosus, 
with  10  per  cent,  of  oil  of  wintergreen  incorporated,  is  even 
more  useful  than  the  oil  alone. 

Patients  are  able  to  bathe  regularly  while  wearing  this 
bandage.  They  often  learn  to  apply  it  properly  themselves. 
Other  adhesive  plaster  bandages  are  those  of  Rosenwater 
and  Eisner  (Figs.  33  and  34),  and  the  ready-made  adhesive 
plaster  bandage  manufactured  in  Germany  at  the  chemical 
works  of  Helfenberg,  near  Dresden  (Figs.  35  and  36). 
None  of  these  bandages  is,  however,  as  satisfying  as  that 
devised  by  Rose. 


Fig.  37 


Position  for  adjusting  corset.      (Gallant.) 


Corsets.  —  The  corsets  most  in  use  are  Bardenheuer's, 
Landau's,  Gallant's,  and  Fitz's,  Bardenheuer's  corsets  consist 
of  an  elastic  pelvic  ring,  from  the  centre  of  which  several 
ribs  radiate  in  a  fan-like  fashion  over  the  abdomen.  These 
are  held  in  position  by  a  strap.  The  Landau  corset  consists 
of  an  elongation  of  the  corset  proper  so  that  the  lower  border 
reaches  as  far  as  the  pubic  bone.  It  is  provided  with  an 
abdominal  strap  which  is  made  to  exert  pressure  by  means 
of  a  steel  spring  upon  a  tin  plate. 

Gallant  advocates  the  semiopisthotonos  posture  (Fig.  37) 


254       ALTERATIONS  IN  POSITION  OF  ABDOMINAL  ORGANS 

as  the  proper  one  for  the  patient  to  assume  in  putting  on 
his  corset.' 

In  an  address  before  the  British  Medical  Association  in 
1888,  Ray  and  Adami  referred  to  the  "physiological  bearing 
of  waist  belts  and  stays."  From  experiments  upon  the 
human  subject,  as  well  as  upon  animals,  these  writers  found 
that  a  large  quantity  of  waste  blood  lay  in  the  abdominal 
viscera.  Gentle  compression  by  a  suitably  fitting  corset 
or  bandage  propels  this  stagnant  blood  into  the  general 
circulation,  and  thereby  increases  muscular  and  mental 
activity.  A  properly  fitting  corset  gives  support  to  the 
lower  abdomen.  These  writers  do  not  advocate  tight 
lacing,  but  prove  that  the  habit  of  wearing  some  form  of 
support  has  a  physiologic  basis  and  is  not  entirely  of  esthetic 
origin. 

The  corset  I  prescribe'  is  an  ordinary  long-hip,  straight- 
front  corset,  and  may  be  purchased  at  any  up-to-date 
corset  shop.  Its  main  feature  is  the  fact  that  it  laces  in 
front.  When  properly  adjusted  it  forms  a  valuable  thera- 
peutic factor  in  the  treatment  of  gastroptosis.  This  is 
especially  true  when  the  abdomen  is  prominent,  protruding 
anteriorly  to  the  spines  of  the  ilium.  The  corset  is  not  so 
beneficial  when  the  abdomen  is  flat;  in  such  cases  the 
author  applies  his  abdominal  bandage.  These  mechanical 
supports  restore  the  abdominal  organs  as  nearly  as  possible 
to  their  normal  position  and  place  the  patient  in  compar- 
ative comfort  while  the  hygienic,  dietetic,  physical,  and 
mechanical  treatment  indicated  for  gastroptosis  or  entero- 
ptosis  is  being  carried  out.  The  reinforcement  of  the  ab- 
dominal wall  restores  intra-abdominal  pressure,  and  thus 
acts  both  directly  and  indirectly  as  a  support  for  the 
abdominal  viscera. 

Method  of  Adjusting  Corset.  —  The  corset  should  be 
opened  the  full  length  of  the  strings  before  hooking.  After 
the  corset  is  hooked  in  front  it  should  be  pulled  down  as 

'  The  Diotctic  and  Hyf^iciiic  Clazctte,  Juiic,  lilOT. 

2  Demonstrated    before    the   Twelfth    Annual    Meeting   of   the   American 
Gastroenterological  Association,  Atlantic  City;  N.  J.,  June  8,  1909. 


PLATE  XI 


FIG.   2 


Method  of  Adjusting 
Author's  Corset. 


Corset  Adjusted  Ready 
to  Lace. 


PLATE  XI 1 


Corset  Laced  froni   Below. 


MECHANICAL  TREATMENT  255 

far  as  possible  by  grasping  the  lower  edge  with  one  hand, 
the  undergarment  being  pulled  up  with  the  other  (Plate  XI, 
Fig.  1).  The  corset  should  be  laced  from  below  up  like  a 
shoe,  thus  gradually  raising  the  displaced  organs.  See  that 
the  clasps  reach  the  groin.  When  the  lower  edge  of  the 
corset  is  half-way  over  the  symphysis,  the  garters  should  be 
fastened  all  around,  and  the  buckles  so  adjusted  as  to  tighten 
the  garters  (Plate  XI,  Fig.  2).  This  must  be  done  before 
lacing.  Beginning  at  the  fifth  eyelet  from  the  bottom,  the 
strings  should  be  pulled  together.  Then  count  three  from 
the  fifth  eyelet  and  pull  the  strings  together.  This  aids 
in  raising  the  abdominal  organs  (Plate  XII).  Now  start 
at  the  top  and  lace  down  to  the  waist  line,  leaving  the 
corset  loose  enough  to  relieve  pressure  in  the  epigastrium 
(Plate  XIII).  The  laces  should  be  tied  at  the  waist  line, 
when  the  corset  will  be  found  to  be  in  proper  position 
(Plate  XIV,  Fig.  1).  This  corset  presses  over  the  hypo- 
gastrium,  so  that  when  it  is  laced  the  lower  abdomen  has 
become  less  prominent  Plate  XIV,  Fig.  2. 

Pregnancy  has  frequently  had  the  effect  of  so  raising  the 
abdominal  organs  as  to  bring  about  recovery  in  cases  of  en- 
teroptosis.  Women  with  ptosis  who  become  pregnant  have  an 
increased  intra-abdominal  pressure,  which  will  vary  directly 
as  the  uterus  increases  in  volume.  Pregnancy  produces  a 
marked  improvement  in  the  digestive  functions  in  these 
cases,  and  there  is  no  reason  why  this  improvement  may  not 
be  made  permanent  through  proper  treatment.  It  becomes 
markedly  apparent  during  the  later  months  of  pregnancy. 
Normal  pregnancy,  then,  does  not  exert  any  bad  influence 
upon  gastroptosis.  If  after  delivery  the  viscera  are  sus- 
tained for  some  time,  a  contraction  of  the  abdominal  walls 
takes  place,  and  in  due  time  the  organs  will  continue  in  their 
proper  position.  During  the  period  of  gestation  the  dis- 
placed organs  are  gradually  forced  up  into  their  normal 
position,  and  the  mesenteries  which  have  been  placed  upon 
the  stretch  have  an  opportunity  to  regain  their  normal 
tonicity.  After  delivery  the  abdominal  walls  should  recede 
and  hold  the  organs  in  normal  position.     Although  preg- 


256      ALTERATIONS  IN  POSITION  OF  ABDOMINAL  ORGANS 

nancy  is  admittedly  a  predisposing  cause  of  enteroptosis, 
a  few  cases  have  come  before  me  in  which  it  served  as  a 
cure.^  After  deUvery  the  patient  should  be  confined  to  the 
bed  longer  than  the  usual  time,  to  be  certain  that  there  will 
be  no  dragging  upon  the  mesentery.  She  should  have  the 
freedom  of  the  bed  for  at  least  three  weeks  and  not  be  per- 
mitted to  get  up  except  for  micturition  and  defecation.  A 
firm  band  should  be  applied  to  the  abdomen,  tightened 
morning  and  night,  so  that  the  organs  will  remain  in  situ. 
At  the  end  of  three  weeks  the  patient  should  be  permitted 
to  get  up  for  an  hour  a  day,  and  afterward  for  a  longer  time. 
From  experience  with  many  cases  of  this  class  I  would 
conclude  that: 

1.  Dispensing  with  the  abdominal  bandage  after  preg- 
nancy, according  to  the  new  method  of  obstetricians,  pre- 
disposes to  gastroptosis. 

2.  Pregnancy  often  favors  the  cure  of  gastroptosis. 

3.  Patients  with  gastroptosis  need  not  hesitate  to  become 
exposed  to  pregnancy. 

4.  The  disagreeable  symptoms  of  gastroptosis  frequently 
disappear  during  the  period  of  gestation. 

5.  Keeping  the  patient  in  bed  after  delivery  and  applying 
an  effective  abdominal  binder  is  very  helpful  in  the  cure  of 
gastroptosis. 

6.  Early  convalescence  after  delivery  and  insufficient 
support  to  the  abdomen  predispose  the  patient  to  gas- 
troptosis. 

Medicinal  Treatment.  —  In  the  majority  of  cases  of  entero- 
ptosis the  administration  of  drugs  occupies  a  very  minor 
place.  Improvement  in  the  appetite  sometimes  follows  the 
administration  of  a  stomachic.  Where  atony  is  present  the 
medicinal  agents  appropriate  for  that  condition  may  be 
given. 

Mineral  waters,  when  they  seem  to  be  indicated,  should 
be  prescribed  tentatively  according  to  the  principles  given 
for  the  treatment  of  atony.  In  cases  where  there  is  much 
distress,  mineral  waters  are  contraindicated. 

*  Aaron,  Enteroptosis  and  Pregnancy,  Medical  Index- Lancet,  June,  1902. 


PLATE  XIII 


Corset  Laced  from   Above. 


PLATE  XIV 


FIG.    I 


FIG.   2 


Corset  Adjusted  Corr-ectly, 
Front  View. 


Corset  Adjusted  Correctly, 
Side  View. 


SURGICAL  TREATMENT  257 

Surgical  Treatment. — Operative  measures  have  been  em- 
ployed for  the  reUef  of  severe  symptoms  incident  to  gas- 
troptosis  and  enteroptosis  of  marked  degree.  One  of  these 
is  the  fixation  of  the  stomach  to  the  parietal  peritoneum 
by  the  shortening  of  the  ligaments  (gastropexy) .  The 
operation  for  nephropexy  has  been  also  employed.  The 
results  of  these  operations  have  not  been  favorable.  Opera- 
tive intervention  seems  to  be  indicated  only  when  gastro- 
ptosis  leads  to  secondary  complications,  such  as  stenosis 
of  the  pylorus  or  duodenum. 

Duret,^  of  Lille,  in  1894,  raised  the  ptotic  stomach  of  a 
woman,  aged  thirty  years,  by  suturing  the  anterior  part  to 
the  abdominal  wall  by  a  single  suture.  Davis-  attached  the 
lesser  omentum  of  the  stomach  to  the  anterior  abdominal 
wall.  Roosing^  elevated  the  stomach  by  passing  three  rows 
of  sutures  from  that  organ  to  the  parietal  peritoneum. 
Webster,  in  1891,  resected  and  sutured  the  fascia  of  the 
gastric  muscles.  Laur^  attached  the  colon  by  suture  at  both 
the  splenic  and  hepatic  flexures  to  the  anterior  abdominal 
wall.  R.  C.  Coffee'^  describes  an  operation  whereby  he  sus- 
pended the  stomach  in  a  hammock  made  of  the  great 
omentum.  Henry  D.  Beyea*^  describes  an  original  operation 
for  the  elevation  of  the  stomach  in  gastroptosis — the  sur- 
gical plication  of  the  gastrohepatic  and  gastrophrenic  liga- 
ments with  three  rows  of  interrupted  sutures.  Cumston 
united  the  recti  muscles  with  kangaroo  tendon  suture  so  as 
to  cause  overlapping,  and  resected  the  excess  of  the  anterior 
aponeurosis,  uniting  with  a  second  layer  of  kangaroo  tendon. 
The  removal  of  all  redundant  skin  was  effected  by  an 
elliptical  incision.  Ernest  Laplace,  of  Philadelphia,  devised 
an  operation  to  suture  the  gastrocolic  omentum  to  the 
anterior  abdominal  wall  by  means  of  continuous  catgut 
suture. 

1  Revue  de  Chirurgie,  1S96. 

2  Western  Medical  Review,  1897. 

3  Archiv  ftir  Chirurgie,  1899. 

*  Presse  Medicale  Beige,  1901. 
^  Philadelphia  Medical  Journal,  October  11,  1902. 
"  Ibid.,  February  7,  1903. 
17 


258       ALTERATIONS  IN  POSITION  OF  ABDOMINAL  ORGANS 

The  results  obtained  by  these  operations  have  not,  how- 
ever, been  encouraging;  and  since  surgical  intervention  has 
proved  ineffectual  in  the  treatment  of  gastroptosis  and 
enteroptosis,  gastroenterologists  have  practically  ceased  to 
advise  it. 

According  to  Fenwick/  when  gastric  displacement  is  due 
to  organic  stenosis  of  the  pylorus  or  duodenum,  gastro- 
enterostomy is  usually  sufficient  without  suturing  the  stomach 
to  the  liver  or  abdominal  wall.  Fixation  of  the  right  kidney 
has  no  effect  whatever  upon  a  coexisting  dislocation  of  the 
stomach,  and  usually  increases  the  gastric  symptoms  by 
the  induction  of  nervous  shock. 

^  Dyspepsia:  Its  Variety  and  Treatment,  1910. 


CHAPTER    XI 

MOTOR  NEUROSES:  HYPERMOTILITY— PERISTALTIC  UNREST— 
CARDIOSPASM— PYLOROSPASM— ERUCTATIONS— PNEUMO- 
TOSIS  —  VOMITING  —  RUMINATION  —  REGURGITATION  — 
PYLORIC  INSUFFICIENCY—  SINGULTUS  GASTRICUS 

NERVOUS  AFFECTIONS   OF  THE   STOMACH 

It  is  often  difficult  to  establish  a  diagnosis  of  a  purely 
nervous  or  functional  derangement  of  the  stomach — that 
is,  to  be  certain  that  no  organic  disease  is  present.  It  is 
also  difficult  to  ascertain  whether  or  not  the  fundamental 
neurasthenia  lying  at  the  bottom  of  every  neurosis  of  the 
stomach  is  the  primary  cause. 

Neuroses  of  the  stomach  are  differentiated  from  organic 
conditions  by  the  one  predominant  symptom,  referable  to 
the  motor,  secretory,  or  sensory  functions.  This  symptom 
has  been  termed  ''nervous  dyspepsia."  Writers  have  pro- 
ceeded in  various  ways  to  classify  the  neuroses  of  the 
stomach.  Some  endeavor  to  draw  distinct  lines  of  demar- 
cation between  motor  and  secretory  and  sensory  neuroses, 
and  speak  of  nervous  dyspepsia  as  a  disease  in  itself,  in 
which  there  may  be  present  combinations  of  motor,  secre- 
tory, and  sensory  disturbances,  giving  rise  to  purely  sub- 
jective symptoms.  Wegele  differentiates  between  irritative 
and  depressive  forms  of  these  neuroses.  Boas  divides 
gastric  neuroses  into  monosymptomatic,  which  include 
motor,  sensory,  and  secretory,  and  polysymptomatic.  Other 
authors  class  under  the  term  "nervous  dyspepsia"  the  entire 
range  of  gastric  disturbances  (Zweig). 

Gastric  neuroses  develop  principally  in  individuals  of  a 
nervous  temperament — that  is,  in  neurasthenics,  hypochon- 
driacs, and  hysterical  persons.  Treatment  must  be  directed 
to  the  symptoms  as  they  present  themselves.     Drugs  which 


2(30  MOTOR  NEUROSES 

have  a  specific  action  upon  the  nervous  system  are  indicated 
in  these  conditions.  Regulation  of  diet,  hyperalimentation, 
education  of  the  patient  to  a  rational  mode  of  life,  hydro- 
therapeutics,  gymnastics,  electricity,  massage,  are  all  of 
value.  The  physician  may  exercise  a  profound  influence 
over  the  patient's  mental  condition  when  he  is  able  to  do  so; 
the  progress  of  the  case  toward  recovery  will  be  much  more 
rapid  than  it  would  otherwise  be.  The  prognosis  will 
depend  largely  upon  the  duration  of  the  treatment,  which, 
in  the  majority  of  cases,  must  be  protracted. 


HYPERMOTILITY 

"  Hypermotility"  is  a  term  which  designates  an  abnor- 
mally increased  movement  in  the  evacuation  of  the  stomach,, 
so  that  the  viscus  is  often  found  empty  soon  after  the  inges- 
tion of  food.  Hypermotility  may  occur  in  cases  of  achylia 
gastrica,  the  closure  of  the  pylorus  being  defective  on  account 
of  the  diminution  or  absence  of  hydrochloric  acid  secretion; 
or  it  may  occur  with  any  other  variety  of  pyloric  insuffi- 
ciency. Cases  of  purely  neurogenous  hypermotility  are 
rare.  The  diagnosis  is  established  by  means  of  a  test 
breakfast.  Hypermotility  does  not  often  give  rise  to  dis- 
tressing symptoms,  and  consequent!}'  does  not  require  any 
particular  treatment. 


PERISTALTIC  UNREST   OF  THE   STOMACH 

The  complex  of  symptoms  first  described  by  Kussmaul, 
and  attributed  })y  him  to  peristaltic  uni-est  of  the  stomach, 
does  not  often  occur  as  a  pure  neurosis.  The  condition  con- 
sists in  the  supervention  of  increased  peristaltic  motions  of 
the  stomach.  Patients  experience  sensations  of  constant 
"griping  and  moving"  in  the  stomach  and  abdomen.  When 
the  abdominal  walls  arc  tliin  and  the  stomach  more  or  le.ss 
ptotic,  it  is  possible  for  tlic  cxaniiiuM-  lo  (lis('(>rn  Iho  actual 


PERISTALTIC   UNREST  OF  THE  STOMACH  261 

peristaltic  movements  of  the  stomach.  These  movements 
are  invisible  through  the  abdominal  wall  when  the  stomach 
is  in  its  normal  position.  A  more  or  less  rapid  peristalsis  is 
occasionally  accompanied  by  rolling  sounds  which  can  be 
heard  at  some  little  distance  from  the  patient.  This  condi- 
tion is  often  present  in  stenosis  of  the  pylorus.  In  making 
the  diagnosis,  mechanical  obstruction  about  the  pylorus  as 
well  as  disturbances  of  gastric  secretion  must  be  ruled  out. 
Treatment.  —  The  treatment  consists  in  combating  the 
cause  as  well  as  the  general  nervous  symptoms  present. 
Excessive  exertion,  both  mental  and  physical,  must  be  care- 
fully avoided.  Nutrition  should  be  regulated  in  order  to 
avoid  the  ingestion  of  anything  that  might  irritate  the 
stomach;  the  food  should  be  of  a  bland,  semiliquid  nature, 
and  too  great  a  quantity  should  not  be  permitted  at  any 
one  time,  for  fear  of  overdistending  the  stomach.  The 
evening  meal  should  be  light.  While  the  loading  of  the 
stomach  with  bulky  foods  should  be  avoided,  it  is  neces- 
sary to  prescribe  the  most  nutritious  regimen  possible. 
The  milk  cure,  combined  with  rest  in  bed,  is  worthy  of 
trial.  The  direct  local  treatment  consists  of  either  cold 
or  warm  applications  over  the  stomach,  with  lavage  in  the 
presence  of  dilatation  and  pyloric  stenosis.  Electric  treat- 
ment in  the  form  of  either  the  galvanic  or  faradic  current, 
external  or  intraventricular  galvanization,  may  be  employed 
with  the  cathode  either  upon  or  inside  the  stomach.  Some- 
times confining  the  patient  to  bed  and  resorting  to  rectal 
feeding  gives  good  results,  owing  to  the  physiologic 
rest  thus  afforded  the  stomach.  A  two  weeks'  course  of 
nutritive  enemata  (see  page  407)  often  results  in  complete 
recovery.  The  drug  indications  include  the  use  of  the 
bromides:  strontium  bromide,  1  Gm.  (15  grains)  four  times 
a  day  in  water,  or  codeine  phosphate,  0.01  to  0.03  Gm. 
(e  to  2  grain)  every  two  to  three  hours,  may  be  prescribed 
for  the  relief  of  pain.  Extract  of  belladonna,  0.01  Gm. 
(^  grain),  sometimes  affords  great  relief.  For  gouty  pa- 
tients Hemmeter  recommends  sodium  salicylate,  1.25  Gm. 
(20  grains),  and  bismuth  subnitrate,  1  Gm.  (15  grains)  three 


262  MOTOR  NEUROSES 

times  a  day.  Vibratory  massage  over  the  left  side  of  the 
tenth,  eleventh,  and  twelfth  dorsal  vertebrae  has  also  given 
relief  in  this  condition;  it  should  be  performed  daily,  the 
treatment  lasting  five  minutes. 


CARDIOSPASM 

Cardiospasm  is  a  condition  in  which  the  cardiac  orifice  of 
the  stomach  contracts  at  the  point  of  junction  with  the 
esophagus.  The  esophagus  becomes  closed  up  at  its  lower 
extremity  at  the  moment  of  swallowing,  so  that  it  is  impos- 
sible for  either  solids  or  liquids  to  enter  the  gastric  cavity. 
Under  normal  conditions  the  cardia  is  capable  of  contraction 
and  relaxation  (Meltzer).  The  contractile  force  is  situated  in 
the  cardia  itself,  while  the  power  of  relaxation  is  controlled 
from  the  medulla  oblongata,  whence  the  inhibitory  impulses 
proceed  to  the  cardia  through  the  pneumogastric.  During 
each  act  of  swallowing,  inhibitory  impulses  pass  from  the 
medulla  to  the  cardia,  causing  the  latter  to  open  to  receive 
the  bolus  of  food.  In  cardiospasm  this  inhibitory  control  is 
apparently  absent,  so  that  the  cardia  remains  in  a  state 
of  continuous  contraction.  Cardiospasm  is  probabh'  due 
to  an  affection  of  the  pneumogastric  nerve. 

Symptoms.  —  Examination  of  the  cardia  in  this  condition 
has  revealed  hypertrophy  of  the  muscles  and  slight  atrophic 
changes  in  the  pneumogastric  nerve.  Cardiospasm,  as  a 
rule,  starts  suddenly  during  eating,  and  may  pass  off  rapidly ' 
(acute  cardiospasm);  or  it  may  persist  for  a  long  time. 
When  the  condition  becomes  chronic,  patients  while  eat- 
ing experience  a  sensation  of  pressure  in  the  chest,  which 
at  times  assumes  the  character  of  spastic  pains  radiating 
toward  the  bowels.  The  morsel  of  food  is  felt  sticking  in 
the  esophagus,  only  to  pass,  after  a  time,  into  the  stomach ; 
or  retching  may  cause  its  regurgitation  into  the  mouth. 
When  cardiospasm  of  this  character  continues  for  any  con- 
siderable length  of  time,  a  loss  in  weight  results,  due  to 
undernutrition.      Retained    food    causes    irritation   of    the 


CARDIOSPASM  263 

esophageal  mucous  membrane,  and  the  esophagus  in  severe 
cases  becomes  dilated  above  the  cardia. 

Diagnosis.  —  The  diagnosis  of  cardiospasm  is  made  by 
close  observation  of  both  subjective  and  objective  symptoms. 
The  objective  examination  consists  in  the  introduction  of  a 
soft  stomach  tube  or  esophageal  bougie,  which,  in  the  pres- 
ence of  cardiospasm,  is  grasped  by  the  cardia  and  retained 
by  the  spastic  muscular  contraction.  The  spasm  relaxes 
only  after  a  period  of  waiting.  Under  any  other  condition, 
except  obstruction  by  benign  or  malignant  growth,  the  cavity 
of  the  stomach  may  be  easily  reached.  This  phenomenon  is 
characteristic  of  cardiospasm.  Dilatation  of  the  esophagus 
is  ascertained  by  the  presence  of  undigested  food  remnants. 
Another  feature  of  diagnostic  importance  is  the  fact  that  the 
so-called  second  sound  of  deglutition  appears  late  or  is  often 
absent  in  cardiospasm.  Meltzer  refers  to  the  diagnostic 
importance  of  the  inability  to  vomit  in  determining  spasm 
of  the  cardiac  orifice.  The  diagnosis  of  this  condition  may 
be  further  confirmed  by  esophagoscopy,  and  the  Roentgen- 
ray  examination  after  the  use  of  bismuth  suspension. 

Prognosis. — The  prognosis  of  cardiospasm  is  always  uncer- 
tain. Acute  cardiospasm  occasionally  disappears  entirely, 
or  reappears  only  at  rare  intervals.  In  chronic  cardiospasm 
the  prognosis  is  less  favorable  for  complete  cure,  and  the 
disease  must  always  be  regarded  as  serious. 

Treatment. — The  treatment  of  cardiospasm  consists  in 
the  treatment  of  the  neurotic  conditions  underlying  it. 
The  psychic  factor  of  treatment  is  important,  and  patients 
must  be  reassured  by  the  physician  that  the  dread  of  swal- 
lowing which  is  always  present  may  be  dispelled.  The 
patient  should  be  prevailed  upon  to  perform  the  act  of 
deglutition  several  times  without  any  food  in  the  mouth 
before  each  meal,  after  which  he  should  attempt  to  eat.  His 
attention  during  meals  should  be  diverted  from  his  condition. 
Change  of  location,  change  in  the  usual  habits  of  life,  as 
well  as  a  different  arrangement  of  the  meal  hours,  will  some- 
times be  accompanied  by  favorable  results.  All  articles  of 
diet    apt    to   irritate    the    esophagus    should    be   avoided. 


264  MOTOR  NEUROSES 

Patients  must  be  instructed  to  eat  slowly  and  to  masticate 
their  food  thoroughly.  Extremes  of  temperature  in  food 
and  beverages  should  be  avoided.  Liquids  containing  much 
carbon  dioxide,  as  well  as  acid  or  highly  seasoned  foods,  are 
not  well  borne  by  patients  in  this  condition.  It  is  important, 
likewise,  that  the  consistency  of  the  food  should  be  liquid 
or  semisolid,  though  sometimes  patients  can  swallow  solid 
food  to  better  advantage  than  liquid.  A  highly  nutritious 
diet  with  as  little  bulk  as  possible  should  be  the  rule  for  these 
patients.  Sometimes  nutritive  enemata  are  indicated,  and 
may  be  given  for  more  or  less  prolonged  periods  of  time, 
affording  rest  to  the  esophagus  and  cardia. 

Oil  Cure. — The  oil  cure  as  recommended  for  stenosis  of 
the  cardia  should  be  employed  in  the  treatment  of  cardio- 
spasm, and,  as  in  the  treatment  of  cardiac  stenosis,  mayon- 
naise and  almond  milk  may  be  given  as  a  substitute  for  olive 
oil.  Drug  treatment,  as  a  rule,  has  no  direct  effect  upon  the 
spasm.  In  selected  cases,  however,  extract  of  belladonna 
has  given  fair  results.  Suppositories  of  atropine  or  eumydrin 
may  be  prescribed.  Bromides  in  large  doses  are  also  indi- 
cated. In  painful  cases,  benefit  has  been  derived  from  the 
administration  of  milk  of  almonds  with  the  addition  of 
anesthesin. 

Mechanical  Treatment. — Chronic  spasm  of  the  cardia 
should  be  treated  along  mechanical  lines,  and  the  cardia 
must  be  mechanically  dilated  b}^  means  of  sounds. 

B.  W.  Sippy  has  devised  a  valuable  instrument  for  the 
treatment  of  cardiospasm  as  well  as  for  the  dilatation  of 
spasmodic  and  other  strictures  of  the  esophagus.  The  in- 
strument is  particularly  useful  in  hypertrophic  stenosis  of 
the  cardia  due  to  cardiospasm  of  long  duration.  It  must  be 
used  with  great  caution  in  organic  stricture.  The  Sippy 
dilator  is  a  rectangular  rubl)er  l)ag,  three  inches  by  one  and 
one-half,  at  an  upper  corner  of  which  is  attached  a  piece  of 
firm  rubber  tubing  twenty  inches  in  length.  Parallel  to  the 
long  axis  of  the  bag  is  a  piece  of  rubber  tubing  three  inches 
in  length  and  closed  at  one  end.  The  uiijior  end,  which 
remains  open,  is  fastened  in  the  wall  of  the  rubber  bag.    By 


CARDIOSPASM  265 

introducing  a  whalebone  bougie  into  this  tubal  compartment 
the  bag  may  be  guided  to  the  location  of  the  stricture.  The 
danger  of  overdilatation  is  obviated  by  a  firm  linen  sack 
which  encircles  the  rubber  bag.  The  lumen  of  the  linen  sack 
determines  the  degree  of  dilatation  that  may  be  obtained. 
For  treating  cardiospasm  in  adults  with  this  dilator  the  width 
of  the  constricting  linen  band  should  not  be  greater  than  six 
or  seven  centimeters,  and  smaller  sizes  must  be  used  for 
children  or  for  dilating  stenoses  which  have  resulted  from 
malignancy  or  cicatrization.  The  Sippy  dilator  is  intro- 
duced after  slipping  a  rubber  condom  over  the  dilator 
before  inflation  and  tying  it  loosely  about  the  tubing  and 
bougie.  The  air  is  forced  into  the  dilating  chamber  by 
means  of  a  rubber  bulb  pump,  so  that  great  pressure  may  be 
applied  to  the  stricture. 

Jesse  S.  Myer  has  devised  a  dilator  for  cardiospasm.^  The 
cardiac  end  of  this  instrument  consists  of,  from  within  out- 
ward, first  a  rubber  tube,  one-fourth  of  an  inch  in  diameter, 
closed  at  one  end  and  at  the  other  end  continuous  with  the 
esophageal  tube;  next,  extending  for  about  six  inches  up  this 
4-inch  tube,  and  made  air-tight  at  each  end  to  it,  is  a  casing 
of  thin  rubber  known  as  Penrose  rubber  tubing,  which  may 
be  procured  in  three  sizes — No.  1  and  No.  2  for  the  large 
dilator  and  No  2  and  No.  3  for  the  small;  and  encasing  the 
Penrose  rubber  tubing  is  a  bag  made  of  ordinary  w^hite  silk 
wdth  a  diameter  of  about  three  centimeters  (Fig.  38 j.  The 
size  to  which  the  dilator  can  be  distended  depends  upon  the 
limitation  offered  by  the  silk  bag.  The  outer  covering  of  all 
is  Penrose  rubber  tubing,  securely  fastened  by  means  of  silk 
at  either  end.  A  flexible  mandrin  consisting  of  a  steel  cable 
is  used  in  introducing  the  dilator,  and  removed  when  the 
dilator  is  in  proper  position.  The  dilating  process  is  per- 
formed by  means  of  a  large  glass  and  metal  syringe  such 
as  is  used  in  bladder  irrigation.  The  syringe  should  be  of 
at  least  150  Cc.  capacity.     Great  pressure  may  be  exerted, 

^  Presented  at  the  Thirteenth  Annual  Meeting  of  the  American  Gastro- 
enterological Association  at  St.  Louis,  Mo.,  June  6  and  7,  1910. 


266 


MOTOR  NEUROSES 


overstretching  of    the  dilator  being  prevented  by  the  silk 
bag  or  collar. 

Large  esophageal  sounds  or  bougies  should  be  used,  and 
left  in  position  in  contact  with  the  stricture.  It  is  better 
to  begin  with  sounds  of  medium  size  and  to  increase  the 
size  as  the  stricture  yields  to  the  dilating  process.  Special 
dilators  have  also  been  devised  by  Einhorn  and  Plummer, 
the  principle  of  each  being  an  India  rubber  bulb  fixed  to 


Fig.  38 


Myer's  cardia  dilator:    A.  deflated;    B,  inflated;   o,  rubber  bag;  b,  silk  bag;  c,  rubber  bag; 
d,  rubber  tube;   e,  mandrin 


the  gastric  extremity  of  a  thin  gastric  sound..  When  the 
sound  has  been  introduced  as  far  as  the  cardiac  orifice,  the 
rubber  bulb  is  distended  by  means  of  water  pressure. 
Simple  solid  sounds  in  many  cases  prove  as  effectual  as 
those  above  mentioned.  The  metal  spiral  sound  of  Craw- 
cour,  which  consists  of'  a  metal  spiral  tapering  toward  the 
extremity,  has  also  been  pmi)l()ycd;  owing  to  its  pliability 
and  weight,  this  sound  very  easily  passes  through  strictures 
of  almost  any  degree.     The  treatment  by  dilatation  must 


PYLOROSPASM  267 

be  continued  for  a  long  period  if  satisfactory  results  are  to 
be  obtained.  Esophageal  lavage  should  also  be  performed 
during  the  process  of  dilating  the  esophagus.  Regin  recom- 
mends the  insufflation  intb  the  patient's  throat,  immediately 
before  meals,  of  a  small  quantity  of  the  following  powder: 

Gm.  or  Cc. 

I^ — Pulveris  acidi  borici, 

Sacchari  lactis aa  2 . 0  gr.  xxx 

Orthoformi 1.0  gr.  xv 

Pulveris  talci 2.0  gr.  xxx 

Cocainse  hydrochloridi 0.05  gr.  f 

Pulveris  mentholis 0 .  02  gr.  | 

Misce. 

Electrotherapy. — Internal  galvanization  of  the  stomach  has 
been  employed  in  a  few  cases  of  cardiospasm,  and  some- 
times relief  is  only  to  be  procured  by  chloroform  narcosis. 
Surgery,  too,  has  been  employed.  Cohen  and  Mikulicz 
have  forcibly  dilated  the  cardia  directly  from  the  opening 
made  by  gastrostomy.  Martin^  reports  a  case  of  cardio- 
spasm in  which  palliative  treatment  had  been  carried  on 
for  some  months  to  no  effect;  the  patient  made  a  good 
recovery  after  divulsion  of  the  sphincter  of  the  cardiac  orifice. 
Willy  Meyer^  reports  a  case  successfully  treated  by  thora- 
cotomy and  esophagoplication. 


PYLOROSPASM 

Secondary  pylorospasm  is  of  comparatively  frequent  oc- 
currence. Recent  studies  on  the  subject  would  seem  to 
point  to  the  probability  of  spasm  of  the  pylorus  being 
sometimes,  though  rarely,  of  purely  nervous  origin.  The 
diagnosis  may  be  established  by  exclusion  of  the  usual 
causes  of  secondary  spasm  of  the  pylorus,  such  as  car- 
cinoma, gastric  ulcer,  and  secretory  disturbances.  Pyloro- 
spasm of  purely  nervous  origin  occasions  pain  of  greater  or 
less  severity,  together  with  increased  gastric  peristalsis  and 
sometimes  vomiting. 

^  JoxuTial  of  the  American  Medical  Association,  March  4,  1905,  p.  1439. 
2  Ibid.,  May  20,  1911,  p.  14.37. 


268  MOTOR  NEUROSES 

The  differentiation  between  benign  obstruction  of  the 
pylorus  and  pylorospasm  is  frequently  quite  difficult.  One 
of  the  best  methods  of  determining  the  patency  of  the 
pylorus  is  the  use  of  the  Einhorn  duodenal  bucket  (Fig. 
5).  This  is  a  small  gold  bucket,  similar  in  shape  to  the 
stomach  bucket,  attached  to  a  silk  cord.  The  bucket  is 
placed  in  a  capsule  and  swallowed  by  the  patient  and  not 
withdrawn  for  several  hours.  On  withdrawal,  the  contents 
of  the  bucket  are  examined  for  pancreatic  ferments,  and  if 
these  are  found  we  are  reasonably  sure  the  bucket  has  been  in 
the  duodenum,  thus  proving  that  the  pylorus  is  still  patent. 
TMien  the  bucket  has  entered  the  duodenum  the  thread  near 
it  is  golden  yellow,  due  to  the  presence  of  bile.  It  is  im- 
portant that  the  stain  on  the  thread  extend  only  a  short 
distance  (10  to  15  centimeters).  If  one-third  or  more  of  the 
thread  is  bile-stained,  this  would  indicate  a  regurgitation  of 
bile  into  the  stomach,  and  therefore  forbid  any  conclusion 
regarding  the  passage  of  the  bucket  through  the  pylorus. 
The  bucket  will  never  reach  the  duodenum  when  there  is 
a  genuine  pyloric  stenosis,  while  in  pylorospasm  it  passes 
through. 

Treatment. — The  treatment  of  this  condition  consists,  among 
other  things,  of  the  application  of  heat,  the  administration 
of  bromides  and  belladonna,  codeine,  galvanization,  and 
mild  hydrotherapeutic  measures.  A  bland,  non-irritating 
diet  should  be  prescribed,  such  as  that  recommended  in  the 
treatment  of  gastric  ulcer,  and  small  quantities  should  be 
given  during  the  initial  stages  of  treatment  to  avoid  over- 
distention  of  the  stomach. 

Einhorn's  method  of  dilating  the  pylorus  by  means  of  a 
thin  stomach  tube  and  a  small  rubber  bag  should  be 
employed. 

The  Einhorn^  pyloric  dilator  (Fig.  41)  consists  of  a  small 
metal  end  piece  to  which  is  attached  a  thin  rubber  tube 
(8  millimeters  in  circumference  and  1  meter  long),  bearing 
markings:  1  =  40  cm.;  11  =  50  cm.;  111  =  70  cm.;  and  80  cm. 
Right  next  to  the  metal  piece  and  fastened  to  it  and  the 

1  Max  Einhorn,  On  Pylorospasm,  Medical  Reconl,  .];uiu;uy  21,  I'.dl,  i).  97. 


PYLOROSPASM  2G9 

tube  is  a  tiny  rubber  balloon  covered  with  silk  gauze.  The 
tube  is  provided  with  a  few  holes  within  the  balloon,  and 
is  connected  at  its  upper  end  with  a  stopcock  and  a  gradu- 
ated glass  syringe.  The  latter  serves  the  purpose  of  inflating 
the  balloon  with  air. 

Method. — The  pyloric  dilator  is  introduced  in  the  same 
manner  as  the  duodenal  pump  (see  page  437) .  After  empty- 
ing the  rubber  balloon  of  its  air  contents  (this  is  done  by 
drawing  the  piston  of  the  syringe  outward),  the  cock  is 
closed.  The  end  piece  of  the  dilator  is  now  dipped  in  luke- 
warm water  and  introduced  into  the  pharynx  of  the  patient. 
The  latter  drinks  some  water  and  the  instrument  moves 
into  the  stomach.  It  is  now  left  in  the  digestive  tract  for 
several  hours;  or,  better,  it  is  swallowed  before  the  patient 
retires,  and  left  undisturbed  over  night — for  in  pylorospasm 
it  sometimes  takes  a  long  time  for  the  apparatus  to  pass  into 
the  duodenum.  In  the  morning  the  stretching  is  performed. 
Before  doing  this  it  is  necessary  to  ascertain  whether  the 
dilator  is  in  the  duodenum.  This  is  done  by  estimating  the 
length  of  tubing  within  the  digestive  tract  (it  should  be  in 
as  far  as  mark  III,  or  70  cm.) ;  on  drawing  the  tube  slightly 
outward,  it  generally  shows  mark  II  within  the  mouth. 
The  balloon  is  then  inflated  by  means  of  the  syringe.  If 
the  tube  be  now  drawn  forward  there  is  a  sensation  as  if 
the  end  of  the  instrument  were  held  tight  by  something 
that  drags  along  with  it,  not  being  able  to  escape  it.  It 
is  not  permissible  to  use  much  force.  The  balloon  is  then 
made  somewhat  smaller  by  pulling  the  piston  of  the  syringe 
and  thus  deflating  it  slightly.  This  is  repeatedly  done 
until  the  end  of  the  dilator  by  a  slight  pull  passes  through 
the  pylorus.  The  syringe  being  graduated,  one  notes  the 
number  of  cubic  centimeters  of  air  in  the  balloon  during  its 
passage  through  the  pylorus.  While  the  dilator  is  being 
drawn  through  the  stomach  no  resistance  is  felt  until  the 
cardia  is  reached.  Here  the  dilator  should  be  entirely  de- 
flated and  withdrawn — which  is  accomphshed  without 
trouble. '  Should,  however,  resistance  be  encountered  at  the 
introitus  esophagi,  the  patient  should  swallow,  and  while  his 


270  MOTOR  NEUROSES 

larynx  moves  upward  the  instrument  is  gently  removed 
without  the  application  of  any  force. 

The  oil  treatment,  as  outlined  by  Cohnheim,  is  valuable. 
The  oil  should  be  taken  on  the  fasting  stomach.  Hyper- 
chlorhydria  is  frequently  the  cause  of  pylorospasm,  in  which 
case  treatment  of  the  spasm  should  consist  of  proper 
measures  to  counteract  the  hyperacidity.  Useful  drugs  for 
this  condition  are  to  be  found  in  atropine  and  eumydrin, 
together  with  the  alkalies.  Engel  maintained  that  the  so- 
called  congenital  stenosis  of  the  pylorus,  or  the  pylorospasm 
of  infants,  was  caused  by  marked  hyperacidity  or  hyper- 
secretion of  gastric  juice,  which  was  in  turn  possibly  second- 
ary to  congenital  neuroses.  It  was  further  pointed  out 
that  an  early  diagnosis  of  the  condition  might  possibly  be 
obtained  by  examination  of  the  gastric  contents  of  the 
vomiting  infant  for  hyperacidity,  and  that  rational  thera- 
peutics based  upon  a  knowledge  of  the  hyperchlorhydria 
would  offer  hopes  for  better  results  in  the  treatment  of  this 
condition,  which  is  so  commonly  fatal.    (See  Chapter  XIV.) 

Rosenhaupt  advises  injection  into  the  rectum  of  a  con- 
siderable quantity  of  a  4-per-cent.  sodium  chloride  solu- 
tion as  a  means  of  treatment  of  pylorospasm  in  infants. 
The  suggestion  is  based  upon  an  experiment  on  dogs,  in 
which  an  injection  of  this  kind  resulted  in  a  marked  diminu- 
tion in  the  quantity  of  gastric  juice  secreted. 


NERVOUS  ERUCTATIONS   (AEROPHAGY) 

This  condition  is  characterized  by  belching,  which  appears 
to  be  independent  of  the  reception  of  food  and  to  be  caused 
by  reflex  nervous  action;  it  consists  in  eructations  of  air 
accompanied  by  sounds  which  are  audible  at  a  considerable 
distance  from  the  patient.  The  belching  may  persist  for 
hours,  and  in  a  few  cases  it  has  been  reported  to  have  kept 
up  for  days.  The  condition  is  one  which  affects  chiefly 
neurotic  individuals.  The  air  has  gained  entrance  to  the 
stomach  by  some  means,  though  it  is  rare  that  atmospheric 


NERVOUS  ERUCTATIONS  271 

air  is  directly  aspirated  by  the  stomach.  Such  individuals 
are  known  to  have  a  habit  of  eating  or  swallowing  air 
(aerophagy).  Neurotics  suffering  from  indigestion  some- 
times experience  trifling  discomfort  in  the  stomach  which 
they  attribute  to  an  accumulation  of  gas,  and  in  their  efforts 
to  obtain  relief  they  expel  whatever  the  stomach  contains, 
whether  "gas"  or  atmospheric  air,  and  in  the  act  swallow 
more  air. 

Diagnosis. — The  diagnosis  of  this  condition  is  not  difficult 
when  the  phj^sician  has  an  opportunity  to  observe  the 
patient  during  a  spell  of  eructation.  The  presence  of  food 
decomposition  in  the  stomach  should  be  ruled  out  by  exami- 
nation of  the  gastric  contents  removed  by  the  tube. 

Treatment. — The  treatment  of  this  condition  is  largely 
psychic,  and  the  physician  must  impress  upon  the  patient  the 
fact  that  he  can  prevent  the  condition  himself  if  he  will. 
The  nature  of  the  affection  should  be  carefully  explained  to 
the  patient,  and  he  should  be  prevailed  upon  to  cease  the  eruc- 
tation as  well  as  the  frequent  swallowing  movements.  The 
French  recommend  that  the  patient  take  a  cork  between  his 
teeth  to  keep  the  mouth  open  and  prevent  swallowing;  this 
should  be  done  after  meals,  every  day  for  a  protracted 
period  of  time.  The  patient  can  be  instructed  to  wear  a 
tight  collar  so  as  to  make  swallowing  painful  and  attract 
his  attention  to  the  act.  The  underlying  nervous  condition 
will  in  many  cases  yield  to  electricity,  change  of  climate,  or 
hydrotherapeutics.  Hyperalimentation  is  known  to  have 
a  salutary  effect  upon  weakened  patients.  Methodic 
treatment  by  sounds  introduced  into  the  esophagus  is  some- 
times followed  by  beneficial  results.  The  medicinal  agents 
indicated  in  this  condition  consist  of  the  bromides,  bella- 
donna, chloroform  water,  and  preparations  of  valerian. 

Gm.  or  Cc. 

I^ — Bismuthi  salicylatis 15.0  3iv 

Mentholis 1.0  gr.  xv 

Mucilaginis  acacise    .      .      .      .       q.  s.  ad         90.0  5iij 

Misce. 

Sig. — One  teaspoonful  every  three  hours  for  the  next  day  or  two  follow- 
ing irrigation  of  the  stomach  with  six  to  eight  liters  of  water  containing  about 
10  Cc.  of  chloroform  water  per  liter. 


272  MOTOR  NEUROSES 

In  cases  of  aerophagy  accompanied  by  severe  pain,  opium 
or  some  opium  preparation  is  indicated.  Suppositories  of 
opium  and  belladonna  serve  a  good  purpose.  Stern  advises 
the  following  combination  for  intestinal  tympany  following 
aerophagy : 

Gm.  or  Cc. 

I^ — Oleiricini 15.0  Sss 

Pulveris  acacise 7.5  5  ij 

Spirit  us  chloroformi 10.0  oiiss 

Heroini 0.15  gr.  iij 

Tincturae  vanillse 2.0  Tllxxx 

Saccharini 0 .  06  gr.  j 

Aquae q.  s.  ad  100.0  giij 

Misce. 

Sig. — One  teaspoonful  every  hour. 


PNEUMATOSIS    (DRUM-BELLY) 

This  term  is  used  to  designate  a  condition  in  which  the 
stomach  is  greatly  distended  by  air.  The  patient  experiences 
symptoms  which  are  referable  to  the  heart,  such  as  irregu- 
larity in  rhythm,  and  dyspnea,  as  well  as  abdominal  tension. 
Pneumatosis  of  a  purely  nervous  character  is  due  to  the 
habit  of  swallowing  air.  Sometimes  the  condition  is  asso- 
ciated with  spasmodic  simultaneous  closure  of  the  pylorus 
and  cardia,  which  renders  it  impossible  for  the  air  to  escape. 
The  distressing  symptoms  usually  vanish  with  the  expulsion 
of  the  air. 

Treatment. — Pneumatosis  is  treated  as  nervous  eructa- 
tions. The  treatment  should  be  directed  toward  increasing 
the  strength  of  the  organism  as  a  whole.  The  drug  treatment 
consists  of  the  administration  of  bromides,  cocaine,  and 
morphine,  the  latter  to  be  given  either  by  mouth  or  by 
hypodermic  injection.  Boas  recommends  the  extract  of 
Calabar  bean  and  the  extract  of  nux  vomica  as  follows: 

Gm.  or  Co. 

I^ — Extract!  pliyso.stigmatis 0.5  gr.  viiss 

Extract!  nucis  vomicae 1.0  fir.  xv 

Pulveris  extract!  glycyrrh!z:p    .  q.  s. 

Misce  et  ft.  p!l.  no.  1. 

Sig. — One  i)ill  tlircc  tiinc.'^  a  day. 


NERVOUS  VOMITING  273 

Physostigmine  is  the  active  principle  of  Calabar  bean. 
It  is  supposed  to  have  a  stimulating  effect  upon  unstriped 
muscle  fibre. 

If  it  can  be  used  without  too  great  discomfort  to  the 
patient,  the  stomach  tube  will  give  immediate  relief  by 
enabling  the  air  to  escape. 

Fey^  reports  a  case  of  pneumatosis  in  which  he  stretched 
the  cardia  with  a  Gottstein  dilator  after  the  use  of  bougies 
of  progressive  size.  The  permanent  distention  secured  a 
circumference  of  14.5  Cm.  The  patient  still  swallows  air, 
but  readily  expels  it. 

NERVOUS  VOMITING 

Nervous  vomiting  produced  by  disturbances  of  the  nerv- 
ous system,  both  central  and  peripheral,  without  external 
irritation  or  anatomic  lesion,  is  a  purely  functional  disorder. 
It  occurs  without  any  overexertion  and  is  independent  of 
the  quantity  and  quality  of  the  food  ingested.  It  varies  in 
relation  to  the  different  kinds  of  diet ;  is  often  absent  when 
particles  difficult  of  digestion  have  been  eaten,  and  may  be 
present  when  only  suitable  food  has  been  taken. 

Organic  diseases  of  the  central  nervous  system  are  not 
infrequently  accompanied  by  vomiting  of  this  nature. 
The  gastric  crises  of  tabetic  patients  are  of  peculiar  interest 
in  connection  with  this  subject.  They  occur  as  a  very 
early  symptom  of  locomotor  ataxia,  and  consist  in  violent 
attacks  of  vomiting,  usually  accompanied  by  intense  gastric 
pain.  The  vomiting  may  last  for  days,  placing  the  patient 
in  a  very  grave  condition.  There  are  also  purely  motor 
gastric  crises,  which  run  their  course  without  any  sensa- 
tion of  pain,  vomiting  being  the  only  distressing  symptom. 
This  latter  condition  is  not  amenable  to  treatment,  which 
should  be  directed  against  the  cause  rather  than  the  symp- 
tom.    The  cause,  in  a  large  majority  of  cases,  is  syphilis. 

A  few  writers  have  described  attacks  of  what  they  term 
idiopathic  vomiting,  which  resemble  very  closely  the  gastric 

1  Deutsche  medizinische  Wochenschrift,  October  6,  1910. 
18 


274  MOTOR  NEUROSES 

crises,  and  in  which  they  were  unable  to  detect  any  patho- 
logic condition  of  the  spinal  cord.  Nervous  vomiting  is 
also  frequently  found  in  hysterical  patients  and  in  neuras- 
thenics; it  adds  sometimes  to  the  distressing  symptoms  of 
patients  suffering  from  enteroptosis,  atony,  and  nervous 
dyspepsia.  Organic  conditions,  however,  must  be  excluded 
before  a  diagnosis  can  be  established.  Nervous  vomiting 
is  very  characteristic.  It  takes  place  with  seeming  ease, 
without  preceding  nausea;  it  is  likewise  independent  of  the 
quality  of  the  food,  but  largely  influenced  by  psychic  causes. 
The  general  nutrition  is,  as  a  rule,  easilj^  maintained. 

Treatment.  —  The  treatment  of  emesis  of  purely  nervous 
origin  is  identical  with  that  of  neurasthenia,  hysteria, 
and  enteroptosis.  In  the  presence  of  obstinate  vomiting, 
recourse  may  be  had  to  drug  treatment,  when  such  seda- 
tives as  cocaine,  menthol,  morphine,  chloral  hydrate,  valerian, 
validol,  menthol-valerian,  chloroform  on  ice,  orthoform, 
or  anesthesin  may  be  used.  Sokolsky  reports  a  case  of 
hyperemesis  gravidarum  which  was  completely  cured  by  eight 
injections,  each  of  1  Cc.  of  a  1-per-cent.  solution  of  cocaine, 
in  the  epigastric  region.  Lemoine^  claims  to  have  found 
the  following  mixture  valuable  not  only  in  the  vomiting 
of  pregnancy  but  also  in  various  cases  of  gastritis : 

Gm.  or  Cc. 

I^— Mentholis 0.3  gr.  v 

Tincturse  opii, 

Tincturae  belladonnse aa        1.0  TTlxv 

Tincturse  hyoscyami 1.0  TTlxv 

Alcoholis 20.0  5v 

Misce. 

Sig. — Five  drops,  in  a  little  water,  every  hour. 

Snowman^  considers  bismuth  one  of  the  best  drugs  for 
the  treatment  of  that  class  of  vomiting  which  results  from 
gastric  irritation,  but  considers  it  of  very  little  use  in  other 
forms.  Cerium  oxalate  (U.  S.  P.)  has  probably  the  same 
action  in  allaying  vomiting  as  bismuth.  It  has  acquired  a 
reputation  in  the  treatment  of  vomiting  of  pregnancy  which 

'  Nord  Medical,  September  15,  1904. 
2  London  Lancet,  March  12,  1910. 


NERVOUS   VOMITING  275 

clinical  experience,  as  a  rule,  fails  to  confirm.  Creo- 
sote, iodine  and  phenol  may  be  grouped  together  as  a 
series  of  drugs  which  allay  vomiting  that  is  produced  by 
fermentative  action  in  the  stomach.  The  vomiting  ceases 
upon  removal  of  the  cause.  Creosote  and  phenol  have, 
however,  a  local  anesthetic  effect  which  may  in  some 
measure  explain  their  anti-emetic  virtue.  Hydrocyanic  acid 
is  another  drug  with  a  reputation  in  gastric  vomiting;  if, 
however,  results  are  not  obtained  immediately,  it  is  useless 
to  persist  with  it.  Aconite,  in  rather  large  doses,  allays 
vomiting  by  numbing  the  reflex  centres  and  thereby  acting 
as  a  powerful  sedative  to  the  peripheral  nerves  in  the  gastric 
mucous  membrane.  It  is  one  of  the  host  of  drugs  suggested 
for  the  vomiting  of  pregnancy.  Chloretone  in  doses  of  0.3 
to  0.5  Gm.  (5  to  8  grains)  relieves  pain  and  allays  vomiting 
resulting  from  some  local  pathologic  cause,  such  as  cancer. 
When  vomiting  is  of  reflex  origin  it  is  worth  while  to  persist 
with  potassium  bromide,  which  may  be  given  per  rectum 
if  not  tolerated  by  the  stomach. 

Rebaudi  reports  a  case  of  hyperemesis  or  pernicious 
vomiting  in  pregnancy  which  yielded  to  treatment  with 
adrenalin.  Ten  drops  of  a  1-to-lOOO  solution  were  given 
every  morning  and  night,  at  first  in  an  enema  of  150  cubic 
centimeters  of  water,  with  20  drops  of  tincture  of  opium, 
and  after  three  days  in  ice  water  by  mouth.  The  vomit- 
ing ceased  by  the  second  day,  when  the  patient  was  able 
to  retain  a  little  food.  The  dose  was  reduced  on  the 
eleventh  day  to  10  drops  a  day  and  continued  for  nine 
days  more. 

Opium  may  be  administered  in  the  form  of  suppositories. 
Morphine  hypodermically  administered  is  a  most  valuable 
remedy  for  vomiting  that  is  persistent  and  exhausting.  It 
acts  unquestionably  as  a  powerful  sedative  to  the  vomiting 
centre,  and  will  afford  relief  as  definitely  as  it  does  in  a 
paroxysm  of  pain. 

Stimulants  to  the  gastric  mucous  membrane,  such  as  the 
following,  have  been  found  effective  in  allaying  vomiting 
of  purely  nervous  origin: 


276  MOTOR  NEUROSES 

Gm.  or  Cc. 
I^ — [Nlentholis 0.1  gr.  iss 

Cocainse  hydro cliloridi 0 .  05         gr.  j 

Alcoholis q.  s.  ad  ft.  sol. 

Aquae  chloroformi 120.0  oiv 

SjTupi  corticis  aurantii 30.0  §] 

Misce. 

Sig. — One  tablespoonful  everj-  two  hours.     (Wegele.) 

Gm.  or  Cc. 

I^ — Tinctura;  iodi 0.5  gr.  viiss 

Spiritus  ^-ini  galhci, 

SjTupi  corticis  aiu-antii        .      .      .      .  aa       30.0  oj 

Misce. 

Sig. — One  teaspoonful  in  half  a  tumbler  of  water  three  or  four  times  a  daj^ 

(Rodari.) 

Gm.  or  Cc. 

I^ — TinctuTse  iodi, 

Chloroformi aa         5.0  5  J 

Misce. 

Sig. — Five  minims  to  be  taken  on  sugar  after  each  meal.     (Wegele.) 

Suggestive  or  psychic  therapeutics  and  the  use  of  gastric 
lavage,  simple  sounding  and  intraventricular  galvanization 
have  produced  favorable  results  with  hysterical  patients. 
Apostoli,  as  early  as  1884,  recommended  galvanism  as 
especially  efficacious  in  the  control  of  vomiting  from  reflex 
causes,  as  well  as  the  h^^sterical  variety.  He  places  the 
positive  pole  on  the  side  of  the  neck  and  the  negative  over 
the  epigastrium,  on  the  assumption  that  the  descending  gal- 
vanic current  passes  along  the  pneumogastric  nerve. 
Another  method,  known  as  Apostoli's  bipolar  method,  con- 
sists in  passing  the  current  transverseh'  through  the  neck 
just  below  the  mastoid  region.  By  experience  it  has  been 
found  that  the  passage  of  the  current  from  one  side  of  the 
neck  to  the  other  is  more  efficient  than  the  neck-to-epigas- 
trium treatment. 

Nervous  vomiting  is  sometimes  induced  reflexly  by  a 
pathologic  condition  of  other  organs.  To  this  class  belong 
the  so-called  vomiting  of  i)regnancy  and  vomiting  of  child- 
hood. 


RUMINATION— MERYCISM  277 


RUMINATION,  MERYCISM 

Rumination  is  an  unhappy  faculty  possessed  by  some 
patients  by  which  they  can  bring  back  at  will  the  food  from 
the  stomach  to  the  mouth  some  time  after  it  has  been  swal- 
lowed, to  be  again  swallowed  or  expectorated.  It  is  more 
common  in  males  than  in  females.  It  affects  neurasthenics, 
hysterical  and  epileptic  persons,  and  sometimes  idiots.  In 
this  class  of  patients  rumination  sometimes  results  from 
fright,  rapid  eating,  overfUhng  of  the  stomach,  traumatism, 
or  irritation  of  the  stomach  by  chemical  or  thermal  agents. 
It  has  been  observed  to  develop  in  other  patients  by  mere 
imitation;  children  of  parents  who  ruminate  are  likely  to 
indulge  in  the  pernicious  practice.  The  exciting  causes 
mentioned  induce,  refiexly,  ante-  or  retro-peristaltic  move- 
ment, which  results  in  the  opening  of  the  cardiac  orifice, 
permitting  the  food  to  regurgitate  to  the  mouth. 

Rumination  is  frequently  preceded  by  nervous  dyspeptic 
symptoms  of  a  mild  nature,  which  become  graduall}^  aggra- 
vated until  the  fluid  contents  of  the  stomach  are  regurgitated. 
Some  persons  appear  to  possess  a  peculiar  power  over  the 
cardiac  orifice,  to  open  or  close  it  at  will.  The  regurgitation 
of  food  is  not  accompanied  by  nausea,  and  in  many  cases 
produces  no  discomfort  whatever.  In  other  cases,  how^ever, 
the  food,  having  remained  for  a  considerable  length  of  time 
in  the  stomach,  has  become  sour  and  disagreeable  to  the 
taste  when  regurgitated;  the  patients,  annoyed,  naturally 
spit  it  out.  As  might  be  expected,  the  habitual  expectora- 
tion of  food  masses  leads  to  marked  emaciation  of  the 
patient.  In  these  cases  the  secretion  of  gastric  juice  may 
show  great  variation  from  the  normal,  or  it  may  be  perfectly 
normal. 

Treatment. — Psychotherapeutics  must  be  resorted  to  as  the 
chief  factor  in  the  treatment  of  these  cases.  The  patient 
must  be  energetically  persuaded  to  suppress  the  regurgita- 
tion of  food.  The  nervous  condition  underlying  the  perni- 
cious habit  requires  appropriate  treatment.     As  a  prophy- 


278  MOTOR  NEUROSES 

lactic  measure,  patients  should  be  instructed  to  eat  slowly 
and  to  thoroughly  masticate  their  food.  Such  patients 
should  not  be  left  alone,  either  during  the  meal  or  for  some 
little  time  afterward,  since  the  presence  of  company  imposes 
a  salutary  restraint  on  the  ruminating  habit.  When  the 
desire  to  ruminate  arises,  expiration  should  be  postponed 
for  a  moment  or  two  and  swallowing  movements  suppressed. 
Patients  should  not  talk  while  eating.  It  is  important  that 
defective  teeth  be  either  repaired  or  extracted.  Children 
should  be  kept  away  from  ruminants  in  order  to  avoid  con- 
tracting the  habit  by  imitation.  Good  results  have  followed 
the  administration  of  acids  in  achylia,  and  large  doses  of 
alkalies  in  hyperacidity.  Sometimes  the  patient  experiences 
pain  of  greater  or  less  severity  in  the  region  of  the  stomach 
when  he  attempts  to  suppress  the  practice  of  rumination, 
and  in  such  cases  w^arm  applications  or  suppositories  in 
which  narcotic  drugs  are  incorporated  assist  in  relieving  the 
distress.  The  bromides  and  strychnine  are  also  indicated. 
The  chief  requirement  in  the  treatment  of  this  form  of 
gastric  neurosis  is  to  fortify  the  will  power  of  the  patient 
sufficiently  to  suppress  the  practice. 

Ferrannini  has  reported  favorable  results  from  the  use  of 
atropine  in  the  treatment  of  merycism  or  rumination;  any 
digestive  disturbances  that  may  be  present,  however,  must 
be  first  corrected.  The  masticatory  apparatus  must  be  kept 
in  proper  condition  by  the  dentist.  Lincoln,  while  empha- 
sizing suggestion  in  treatment,  also  advises,  when  the  regur- 
gitation is  habitual,  that  the  patient  be  forced  to  swallow 
the  regurgitated  food.  Meals  should  be  served  in  company. 
The  administration  of  a  bitter  preparation,  as  quinine,  with 
the  meals  is  likely  to  do  away  with  any  desire  to  ruminate. 


REGURGITATION 

Regurgitation  proper  is  a  condition  in  which  the  food 
returns  involuntarily  from  (ho  stomach  to  the  mouth  and 
is  expectorated.      It    may   occur  in  health,    but   becomes 


A  Case  of  Pyloric  Insufficiency. 

The  Roentgenograni  was  taken  ininnediately  after  the  patient  was  given 
one  ounce  of  bismuth  subearbonate  in  twelve  ounces  of  koumiss.  The 
dark  area  outlining  the  stomach  shows  that  the  organ  is  almost  eonipletely 
filled,  practically^  none  of  the  test  meal  having  passed  through  the  pylorus. 
A  coin  covers  the  umbilicus. 


PLATE  XVI 


A  Case  of  Pyloric   Insufficiency. 

The  Roentgenograni  -vvas  taken  one- half  hour  after  patient  was  given 
one  ounce  of  bismuth  subearbonate  in  twelve  ounces  of  koumiss.  Com- 
paring this  writh  the  preceding  plate,  'we  find  that  the  dark  area  (outlined 
by  the  bismuth)  has  decreased  in  size  so  that  only  about  one-eighth  of  the 
ingested  mass  reniains.     A  coin  covers  the  umljilieus. 


PLATE  XVI 1 


A  Case  of  Pyloric  Insufficiency. 

The  Roentgenogram  was  taken  immediately  after  the  patient  was  given 
one  ounce  of  bismuth  subearbonate  in  twelve  ounces  of  koumiss.  The 
round  dark  shadow  is  a  coin  fastened  over  the  umbilicus.  The  dark  area 
above   shows  the  outline  of  the  stomach    filled   with    bismuth. 


INSUFFICIENCY  OF   THE  PYLORUS  279 

pathologic  when  it  persists  over  a  prolonged  period  and 
when  the  quantity  of  food  brought  up  is  large.  Emacia- 
tion results  when  patients  regurgitate  any  considerable  por- 
tion of  the  food  ingested.  The  treatment  of  this  condition 
is  similar  to  that  of  rumination. 


INSUFFICIENCY  OF  THE  PYLORUS 

Pyloric  insufficiency  (see  Plates  XV,  XVI,  XVII,  XVIII, 
and  XIX)  is  a  condition  which  has  been  known  frequently 
to  follow  organic  diseases.  It  has  been  noted  after  destruc- 
tion of  the  sphincter  muscles  of  the  pylorus  by  carcinoma ; 
cicatrices  from  gastric  ulcer  in  the  region  of  the  pylorus; 
duodenal  stenosis;  catarrh  of  the  stomach;  and  achylia. 
Pyloric  insufficiency  from  purely  neurotic  causes  is  of  exceed- 
ingly rare  occurrence.  Among  the  most  important  diag- 
nostic indications  of  pyloric  insufficiency  is  the  fact  that  air 
blown  into  the  stomach  escapes  immediately  into  the  gut, 
thus  rendering  artificial  distention  of  the  stomach  impossible. 
The  flow  of  bile  and  of  the  contents  of  the  small  intestine 
into  the  stomach  is  likewise  suggestive  of  a  relaxed  pyloric 
orifice.     The  diagnosis  is  easily  made  by  means  of  the  x-ray. 

Treatment. — The  treatment  of  pyloric  insufficiency  depends 
upon  the  stage  of  the  disease.  The  clinician  should  endeavor 
to  find  out  if  there  is  any  gastric  secretion,  and  how  soon 
after  the  ingestion  of  food  the  stomach  becomes  empty. 
The  stomach  contents  should  be  aspirated  one  hour  after 
the  test  meal  is  taken.  If  nothing  be  forthcoming,  the  test 
meal  should  be  repeated  on  the  following  morning  and  the 
stomach  tube  used  afc  a  half -hour  interval  after  the  meal. 
If  again  unsuccessful,  the  test  should  be  repeated  on  the 
third  day,  the  interval  after  eating  being  reduced  to  a  quar- 
ter of  an  hour.  By  this  means  it  is  possible  to  ascertain  the 
quantity  of  gastric  contents  present  at  any  time.  The  drugs 
indicated  in  this  disease  are  such  as  aid  intestinal  digestion, 
since  derangement  of  intestinal  digestion,  accompanied  by 
distressing  symptoms,  is  apt  to  arise  from  the  premature 
passage  of  the  food  into  the  duodenum.   The  combinations 


280  MOTOR  NEUROSES 

of  sodium  and  magnesium,  rhubarb,  ammonium  chloride, 
pancreatin,  and  bile  in  the  form  of  inspissated  ox-gall,  are 
about  all  the  drugs  necessary.  Quite  as  important  as  the 
drugs  themselves  is  the  proper  time  after  the  ingestion  of 
food  for  their  administration.  If  it  be  found  that  the 
stomach  is  emptied  immediately  after  eating,  the  drugs 
should  be  prescribed  to  be  taken  immediately  after  eating. 
If,  on  the  other  hand,  the  examination  reveals  that  there  is 
still  some  gastric  digestion  and  that  the  ingested  food  does 
not  immediately  leave  the  stomach,  the  interval  of  time  be- 
tween food  and  medicine  must  be  dete  Tuined  accordingly. 
Hydrochloric  acid  and  pepsin  should  not  be  administered, 
since  they  are  of  practically^  no  use  at  any  time  for  helping 
gastric  secretion  in  this  class  of  cases.  Hydrochloric  acid  can 
never  be  given  in  effective  strength,  and  pepsin  is  very  seldom 
absent  except  in  achylia  gastrica.  In  diarrhea  associated 
with  this  condition,  strychnine  has  been  found  to  give  the 
best  results  (Knapp) .  This  drug  should  be  rapidly  pushed 
to  the  point  of  tolerance.  Many  cases  of  diarrhea  which  have 
existed  for  years  have  been  known  to  respond  most  satisfac- 
torily to  the  administration  of  strychnine  sulphate.  The  stools 
at  once  diminish  in  number  and  gain  in  consistency.  StrjTh- 
nine  has  been  known  to  produce  excellent  results  in  about 
three  and  a  half  weeks  in  diarrhea  resulting  from  insuffi- 
ciency of  the  pylorus. 

Coffee,  tea,  too  rich  cocoa,  carbon  dioxide  waters,  beer, 
wine,  brandy  and  whisky,  beans  and  peas  (unless  their 
cellulose  envelopes  are  removed  after  soaking  in  water  over 
night),  cabbage,  cauliflower,  radishes,  turnips,  spices,  toma- 
toes in  every  form  and  everything  prepared  with  vinegar, 
grapes,  peaches,  plums,  and  prunes,  should  be  denied  this 
class  of  patients.  The  condition  of  the  teeth  should 
be  carefully  looked  after  and  the  necessary  dental  work 
done.  Half  a  teaspoonful  of  sodium  sulphate  in  a  glass  of 
hot  water,  taken  hot  about  half  an  hour  before  each  meal, 
will  best  cleanse  the  stomach  of  any  mucus  that  may  be 
present.  Symptomatic  treatment  is  not  required  in  pyloric 
insufficiency  of  purely  nervous  origin. 


PLATE  XVlll 


A  Case  of  Pyloric  Insufficiency. 

The  Roentgenogram  -was  taken  fifteen  niinutes  after  the  patient  was 
given  one  ounce  of  bismuth  subearbonate  in  twelve  ounces  of  koumiss. 
The  round  dark  shadow  niarks  the  umbilicus.  A  large  quantity  of  the 
bismuth   has  escaped   into  the  small   intestine. 


PLATE  XIX 


A  Case  of  Pyloric  Insufficiency. 

The  Roentgenogram  was  taken  thirty  minutes  after  the  patient  was 
given  one  ounce  of  bisniuth  subeartaonate  in  twelve  ounces  of  koumiss. 
The  round  dark  shadow  marks  the  umbilicus.  Nearly  all  the  bismuth 
has  passed  from  the  stomach  into  the  small  intestine  and  shows  laelow  m 
the  irregular  dark  blotches. 


SINGULTUS  GASTRICUS  281 


SINGULTUS  GASTRICUS 

Singultus,  or  hiccough,  is  a  symptom  manifest  as  a  sound 
made  by  the  sudden  and  involuntary  contraction  of  the  dia- 
phragm and  the  simultaneous  contraction  of  the  glottis  which 
arrests  the  rising  air  in  the  trachea.  Singultus  may  last  for 
a  few  minutes  or  much  longer,  or  it  may  recur  for  days  or 
months.  It  is  a  symptom  often  found  in  diseases  of  the 
abdominal  viscera,  such  as  gastritis,  motor  insufficiency  of 
the  first  and  second  degrees,  gastric  carcinoma,  enteritis, 
intestinal  obstruction,  appendicitis,  cholera,  pancreatitis 
(suppurative),  diseases  of  the  liver,  and  peritonitis;  it  has 
also  been  observed  in  the  course  of  such  diseases  of  the 
nervous  system  as  epilepsy,  tumor  of  the  brain,  meningitis, 
hydrocephalus,  and  hysteria. 

In  rare  cases  of  singultus  gastricus  a  continuous  hiccough 
lasting  for  a  long  time,  varying  from  weeks  to  months, 
and  without  any  gastric  return,  may  be  present.  There 
is  usually,  however,  a  hyperesthesia  of  the  glandular  layer 
of  the  stomach.  It  is  found  usually  in  well-nourished 
young  adults  and  most  often  in  female  patients.  Hiccough 
is  occasionally  a  prominent  symptom  of  gall-bladder  disease 
and  may  be  so  incessant  as  to  produce  alarming  exhaustion. 
According  to  Habershon,  in  most  cases  the  liver  is  at  fault, 
and,  though  the  primary  cause  is  usually  an  indigestible  or 
improper  diet,  it  is  the  congestion  or  disturbance  of  the  liver 
that  is  the  exciting  cause.  The  treatment  should  be  directed 
toward  the  underlying  cause. 


CHAPTER    XII 

SENSORY  NEUROSES  :  GASTRALGIA  —  HYPERESTHESIA  —  G AS- 
TRALGOKENOSIS— NAUSEA— BULIMIA— AKORIA— ANOREXIA 
—EYE  STRAIN 

GASTRALGIA,  CARDIALGIA,  GASTRODYNIA,  NEURALGIA  OF 
THE   STOMACH 

Gastralgia  is  a  condition  peculiar  to  individuals  of  a 
nervous  temperment.  The  diagnosis  of  this  condition  cannot 
be  confu'med  until  a  careful  exclusion  is  made  of  organic  dis- 
eases of  the  stomach  and  intestine  and  the  more  remote  vis- 
cera. The  pains  complained  of  in  gastralgia  are  due  to  morbid 
or  irritating  conditions  of  the  sympathetic  nervous  ganglia 
located  in  front  of  the  spinal  column.  The  site  of  the  pain 
is  the  epigastric  portion  of  the  lumbar  sjTnpathetic.  The 
celiac  plexus,  the  superior  mesenteric  plexus  and  the  aortic 
plexus  may  also  be  involved.  The  location  of  the  pain 
is  in  reality  exterior  to  the  stomach.  The  nervous  gastric 
pains  occur  periodically  and  spasmodically,  and  at  times 
become  so  intense  as  to  be  unbearable.  The  attacks  last 
from  a  few  hours  to  several  days;  the  pains  radiate  toward 
the  back  and  also  up  into  the  chest.  They  are  usually  inde- 
pendent of  the  reception  of  food.  Nervous  excitement  is  apt 
to  bring  on  the  attacks,  during  which  vomiting  rarely  takes 
place.  Eructations  are  common.  The  celiac  plexus  is 
often  markedly  sensitive  to  pressure  exerted  in  the  median 
line  of  the  epigastric  region.  The  superior  mesenteric 
plexus,  as  well  as  the  aortic,  occasionally  becomes  very 
sensitive,  as  elicited  by  pressure  on  two  points  situated 
immediately  above  and  below  the  umbilicus.  There  is 
often  found  a  hyperesthetic  zone  in  the  epigastrium.  The 
differential  diagnosis  between  gastralgia  and  ulcer  of  the 
stomach  is  fraught    with    difficult}-,  and   established   onlj'' 


GASTRALGIA—CARDIALGIA—GASTRODYNIA  283 

after  careful  consideration  of  the  symptoms  of  ulcer,  such 
as  occult  hemorrhage,  pressure  points,  and  relation  of  the 
pains  to  the  reception  of  food.  In  ulcer  the  hyperesthetic 
cutaneous  zone  is  usually  smaller  in  area  than  in  gastralgia. 
Among  the  recognized  causes  of  gastralgia,  Allen  A.  Jones 
says  syphilis  should  be  given  a  more  prominent  place. 

Treatment.  —  The  treatment  of  gastralgia  should  be  di- 
rected toward  the  generally  debilitated  condition  of  the 
patient,  and  should  consist,  among  other  things,  of  hydro- 
therap}',  change  of  climate,  and  the  milk  cure.  Very  little 
or  no  restriction  need  be  made  in  regard  to  diet,  since  the 
condition  is  purely  extragastric.  It  is  not  necessary  that 
patients  should  be  kept  on  either  fluid  or  light  diet.  The 
regimen  may  be  varied  and  generous  in  quantity  with- 
out aggravating  in  any  way  the  painful  symptoms.  The 
diet,  however,  should  be  suited  to  the  individual  case.  It 
will  be  necessary  in  many  cases  of  this  class  to  persuade 
patients  to  eat,  and  to  impress  upon  them  that  there  is  no 
connection  between  the  ingestion  of  food  and  the  pains  of 
which  they  complain,  but  that  there  is  danger  of  aggravating 
the  symptoms  by  abstaining  from  food. 

During  the  acute  attack  the  patient  should  be  put  to  bed 
and  hot  compresses  or  poultices  should  be  applied  to  the 
region  of  the  stomach.  Good  results  are  obtained  by  a  "half 
bath"  or  a  protracted  hot  sitz  bath.  When  the  pains  are  of 
a  violent  nature,  resort  must  be  had  to  such  drugs  as  mor- 
phine or  opium  and  belladonna  in  combination. 

Gm.  or  Cc. 

I^ — Morphinae  sulphatis 0.01             gr.  § 

Extract!  belladonnse 0 .  02             gr.  | 

Olei  theobromatis 2.0               gr.  xxx 

Misce  et  ft.  suppos.  no.  i. 

Sig. — As  required  for  the  relief  of  pain. 

Gm.  or  Cc. 

I^ — Extract!  opii 0 .  05  gr.  | 

Extract!  belladonnse 0 .  02  gr.  | 

Olei  theobromatis 2.0  gr.  xxx 

Misce  et  ft.  suppos.  no.  !. 

Sig. — As  required  for  the  relief  of  pain. 


284  SENSORY  NEUROSES 

Gm.  or  Cc. 

I^ — Cocainse  hydrochloridi 0.5  gr.  viiss 

Aquae  aurantii  .      . 30 . 0  gr.  §  i 

Aquse  chlorof ormi 75 . 0  gr.  §  iiss 

Aquse  destillatae 45.0  oiss 

Misce. 

Sig. — One  to  three  teaspoonfuls  in  water  at  the  beginning  of  the  attack. 

In  severe  cases  morphine  should  be  given  hypodermically 
at  once.  Among  the  medicaments  which  may  be  admin- 
istered per  mouth  are  cocaine  (0.05  Gm.  to  150  Cc.  water, 
in  teaspoonful  doses),  codeine,  dionin,  0.03  to  0.05  Gm. 
(i  to  1  grain),  chloral  hydrate,  antipyrine,  0.5  Gm.  (7^ 
grains),  phenacetine,  1.0  Gm.  (15  grains),  chloroform  water, 
validol,  and  valerian  preparations,  such  as  the  ammoniated 
tincture  of  valerian.  Extract  of  cannabis  indica  has  also 
been  recommended  for  the  pains  of  gastralgia. 

Gm.  or  Cc. 

I^ — Extracti  cannabis  indicse 0 .  03         gr.  ss 

Sacchari  albi 0 .  50         gr.  viij 

Misce  et  ft.  pulv.  no.  i. 
Sig. — One  every  four  hours. 

Gm.  or  Cc. 
I^ — Tincturse  cannabis  indicae        .      .      .      .       4.0  oi 

Tincturse  Valerianae 6.0  5  iss 

Misce. 

Sig. — Twenty  drops  to  be  taken  at  a  dose. 

Hoffman's  anodyne,  20  to  30  drops  on  a  lump  of  sugar,  is 
recommended  by  Einhorn  for  the  treatment  of  this  condi- 
tion. Hot  drinks  such  as  peppermint  tea  or  valerian  tea  are 
productive  of  favorable  results.  If  convenient,  galvaniza- 
tion is  worthy  of  a  trial,  when  the  anode  should  be  placed 
over  the  epigastrium  and  the  cathode  over  the  spinal 
column  for  from  five  to  ten  minutes.  The  faradic  current 
may  also  be  used. 

In  cases  where  pains  are  less  violent  but  of  prolonged 
duration,  massage  and  electricity  are  indicated  in  addition 
to  warm  applications.  Eisner  recommends  a  systematic 
course  of  massage  of  the  epigastrium  in  order  to  reduce  the 
hypersensitive  condition  of  the  sympathetic  plexus.     One 


GASTRALGIA—CARDIALGIA—GASTRODYNIA  285 

or  two  fingers  of  the  right  hand  should  be  appHed  over  the 
epigastric  pressure  point,  and  by  rotating  movements  the 
hand  should  be  made  to  penetrate  gradually  toward  the 
sympathetic  plexus.  In  the  initial  stages  of  the  massage, 
patients  experience  severe  pain,  which,  however,  eventually 
disappears,  and  rapid  improvement  follows.  Intraventric- 
ular galvanization  may  be  practiced  at  the  same  time. 
The  physician  must  persist,  however,  in  this  treatment 
if  he  is  to  obtain  permanent  results. 

A  special  form  of  gastralgia  is  represented  by  the  gas- 
tric crisis  of  locomotor  ataxia,  which  is  characterized 
by  violent  cramps  in  the  stomach  and  pains  in  the  back, 
followed  by  vomiting.  Ewald  maintains  that  idiopathic 
crises,  so  called,  may  be  influenced  therapeutically,  which 
is  hardly  ever  the  case  with  true  tabetic  crises.  As  to 
the  nature  of  these  crises  we  are  still  in  the  dark,  nor 
have  we  by  any  means  been  able  to  cut  short  the  attacks 
except  by  the  use  of  morphine  or  the  injection  of  cocaine 
to  anesthetize  the  posterior  roots.  The  following  drugs 
are  recommended  in  addition  to  the  measures  already 
described  for  the  acute  painful  seizures :  Antipyrine,  0 . 6  Gm. 
(10  grains),  cerium  oxalate,  0.3  to  0.6  Gm.  (5  to  10  grains), 
three  times  a  day;  aspirin  and  the  salicylates. 

Gm.  or  Cc. 

I^ — Sodii  salicylatis 8.0  5ij 

Caffeinse  sodiosalicylatis 2.0  gr.  xxx 

Aquae q.  s.  ad     50.0  §ij 

Misce. 

Sig. — 1  to  2  Cc.  of  the  sterilized  solution  to  be  injected  daily  into  the 
median  vein.     (Von  Mendel.) 

The  majority  of  gastralgias  are  secondary  affections,  and 
may  occur  in  the  course  of  almost  any  infection  of  the 
stomach  or  other  abdominal  organ,  in  arteriosclerosis,  in 
intoxications,  anemia,  and  diseases  of  the  male  and  female 
sexual  organs.  In  gastralgia  resulting  from  these  condi- 
tions treatment  should  be  directed  toward  the  primary 
cause. 

Moszkowicz  and  Gozl/  of   Vienna,  recently  reported  a 

'  Lancet,  June  11,  1910. 


286  SENSORY  NEUROSES 

case  of  gastric  crisis  in  which  the  patient  had  been  brought 
to  such  a  degree  of  despair  that  he  was  prepared  to  undergo 
any  form  of  treatment  that  might  give  promise  of  reUef. 
It  was  resolved  to  divide  the  posterior  roots  of  certain  spinal 
nerves.  The  seventh,  eighth  and  ninth  roots  were  selected 
and  divided,  so  as  to  sever  the  dorsal  portion  which  contained 
the  sympathetic  fibres  leading  to  the  stomach.  Since  the 
operation  the  patient  is  reported  to  have  lost  his  former 
distressing  symptoms  of  incessant  pain,  vomiting,  and  mental 
depression.  He  has  gained  in  weight,  and  the  only  outward 
symptom  due  to  the  operation  is  an  anesthetic  zone  around 
the  abdomen. 

GASTRIC  HYPERESTHESIA 

Gastric  hyperesthesia  is  defined  as  an  increased  sensitive- 
ness of  the  gastric  mucous  membrane  to  chemic,  mechanic, 
and  thermal  stimuli,  or  to  any  one  of  these.  A  patient 
with  a  good  appetite  may  suffer  pain  when  certain  articles 
of  food  or  drink  are  taken,  which  is  not  relieved  until  the 
food  or  drink  has  disappeared  from  the  stomach.  The 
stomach  is  often  hypersensitive  to  sugar,  fat,  and  carbo- 
hydrates. Of  thermal  stimuli  the  stomach  is  more  sensitive 
to  cold  than  to  heat.  The  abnormal  sensations  may  vary, 
amounting  in  some  cases  to  severe  pain  and  vomiting.  Dur- 
ing digestion  there  may  be  sensations  of  fulness,  pressure, 
tension,  or  burning,  but  these  usually  cease  with  the  evacu- 
ation of  the  stomach.  Gastric  hyperesthesia  is  a  condition 
rather  frequent  in  neurasthenic  and  hysterical  subjects. 
Patients  come  to  associate  the  distressful  symptoms  with 
the  ingestion  of  food,  and  as  a  result  the  quantity  of  food 
consumed  becomes  less  and  less  and  the  patient  loses  flesh 
and  strength. 

Treatment.  —  The  treatment  should  be  directed  against 
the  cause.  Efforts  should  be  made  to  improve  the  general 
nutrition,  and,  if  necessary,  a  course  of  hyperalimentation 
should  be  instituted.  Asthenic  patients  re(iuirc  rest  in 
bed,  and  should  be  kept  absolutely  quiet  both  mentally 


GASTRIC  HYPERESTHESIA  287 

and  physically.  The  nutrition  cure  should  be  commenced 
with  caution;  it  should  consist  at  first  of  milk  and  kefir, 
to  be  gradually  changed  to  a  diet  of  semisolid  consistency. 
The  dietary  should  be  such  as  to  reaccustom  the  patient  to 
ordinary  food.  When  the  distaste  for  food  is  very  marked  it 
may  be  necessary,  at  times,  to  resort  to  nutritious  enemata. 
Nitrate  of  silver  is  particularly  effective  in  diminishing 
the  sensitive  condition  of  the  stomach.  A  tablespoonful  of  a 
solution  of  0 . 2  to  0 . 3  Gm.  (3  to  5  grains)  to  100  Cc.  of  water 
is  given  three  times  a  day.  It  is  best  administered  as  a 
tablespoonful  of  the  solution  to  a  wineglass  of  distilled 
water,  before  breakfast,  and  half  an  hour  before  dinner  and 
supper.  Lavage  with  silver  nitrate  solution  (1  to  1000) 
also  acts  well.  When  there  is  much  pain,  belladonna, 
chloroform  or  a  preparation  of  valerian  is  indicated.  Anes- 
thesin  may  be  given  in  doses  of  0 .  25  to  0.5  Gm.  (4  to  7i 
grains),  ten  to  fifteen  minutes  before  meals.  Pick^  recom- 
mends the  faradic  current,  though  he  admits  that  this 
treatment  is  largely  suggestive.  Dr.  Charles  G.  Stockton, 
of  Buffalo,  advises  a  bland  diet,  commencing  with  milk  and 
eggs  and  going  on  to  farinaceous  foods.  He  also  recom- 
mends electricity  and  hydrotherapy,  though  care  should  be 
exercised  against  the  excessive  employment  of  cold  water. 
For  the  relief  of'  gastric  irritation,  Rochester^  advises  the 
following  combination : 

Gm.  or  Cc. 

I^ — Strontii  bromidi 6.0  3iss 

Sodii  bicarbonatis 40.0  5x 

Carbonis  ligni 20.0  3v 

Bismuthi  subcarbonatis 20.0  5v 

Magnesiae ISO.O  5vj 

Misce. 

Sig. — Two  teaspoonfuls  in  water  three  times  a  day,  after  meals. 

If  between  meals  patients  are  troubled  with  burning  or 
pain  in  the  stomach  which  may  be  accounted  for  by  the 
presence  of  hyperacidity,  the  following  will  be  found  a 
satisfactory  gastric  sedative: 

^  British  Medical  Jorunal. 

-  New  York  State  Medical  Journal,  April,  1908. 


288  SENSORY  NEUROSES 

Gm.  or  Cc. 

I^ — Cerii  oxalatis 10.0  5ijss 

Bismuthi  subcarbonatis 20.0  qv 

Magnesii  oxidi 40.0  5x 

Misce.  et.  ft.  pulv.  no.  xviii. 

Sig. — A  powder  stirred  in  water,  and  repeat  in  an  hour  if  needed. 


GASTRALGOKENOSIS 

The  term  "  gastralgokenosis"  was  used  by  Boas  to  desig- 
nate stomachache,  or  the  sensation  of  painful  pressure  in 
the  region  of  the  stomach  when  that  viscus  was  empty. 
In  this  condition  there  is  hyperesthesia  of  the  empty 
stomach.  The  pain  may  become  very  severe  a  few  hours 
after  eating,  when  the  stomach  is  empty.  Excess  of 
hunger  has  never  been  observed  to  accompany  this  con- 
dition, though  pain  is  promptly  relieved  by  the  ingestion 
of  food. 

The  patient  should  endeavor  to  ward  off  the  attack  bj'' 
never  permitting  the  stomach  to  become  quite  empty. 
He  should  have  with  him  always  some  articles  of  food,  such 
as  crackers  or  milk.  Small  doses  of  extract  of  opium, 
0.006  to  0.008  Gm.  (yV  to  i  grain),  and  the  bromides,  are 
indicated  for  this  condition. 


NERVOUS  NAUSEA 

Idiopathic  nausea  appears  most  frequently  in  women  and 
in  consequence  of  a  general  neurotic  condition,  anemia  and 
chlorosis,  or  disturbance  of  the  menstrual  function.  Purely 
functional  nausea  may  occur  at  intervals.  Mental  excite- 
ment acts  as  an  exciting  cause.  Nervous  nausea  may  occur 
in  the  morning  while  the  stomach  is  empty  after  the  night's 
fast.  During  these  spells  patients  experience  a  pronounced 
aversion  to  food.  The  disease  may  at  times  assume  an  ob- 
stinate form,  which  Boas  attributes  to  the  variable  condition 
of  the  blood  supi)ly  to  the  bruin.     The  gastric  functions,  in 


BULIMIA  289 

the  majority  of  cases,  are  normal;  rarely  a  moderate  degree 
of  hyperacidity  may  be  present. 

Treatment. — When  the  nausea  is  due  to  neurasthenia  or 
anemia,  these  conditions  should  receive  attention.  Anemia 
may  be  improved;  that  is,  hemoglobin  can  be  rapidly 
increased  by  the  hypodermic  use  of  the  citrate  of  iron,  as 
described  on  page  240.  Sometimes  the  food  cure  should 
be  instituted  in  cases  where  the  general  nutrition  is  low. 
Patients  occasionally  do  well  when  removed  from  their 
homes  and  customary  surroundings.  Particular  attention 
should  be  paid  to  the  mental  state  of  the  patient,  which 
is  often  depressed.  Severe  cases  should  be  treated  in  a 
properly  conducted  hospital  or  a  sanitarium.  Food  should 
be  served  in  an  attractive  manner,  for  the  sake  of  its  appe- 
tizing influence  and  the  pleasure  which  details  of  this  kind 
give  the  patient.  Should  there  be  nausea  early  in  the 
morning,  it  will  be  well  to  serve  breakfast  in  bed.  Hydro- 
therapeutics  will  be  found  a  valuable  factor  in  the  treat- 
ment. Zweig,  as  a  means  of  cutting  short  the  attack  of 
nausea,  recommends  a  bath  of  64°  F.  or  a  cold  douche. 
Both  intraventricular  and  extra  ventricular  galvanization 
may  be  employed.  The  bromides,  chloral  0.2  to  0.3  Gm. 
(3  to  5  grains)  three  or  four  times  daily,  and  validol  (six 
to  eight  drops  every  two  to  three  hours)  are  indicated  in 
the  treatment  of  nervous  nausea. 


BULIMIA 

Bulimia,  cynorexia,  and  hyperorexia  are  terms  used  to 
designate  a  condition  in  which  the  sensation  of  hunger  is 
more  frequent  and  more  intense  than  in  the  normal  state. 
Bulimia,  as  it  is  called,  may  be  a  primary  affection,  or  it 
may  be  associated  with  various  other  diseases,  as  gastric 
ulcer  or  cancer,  hyperacidity,  affections  of  the  pancreas, 
exophthalmic  goitre,  hysteria,  neurasthenia.  There  is  an 
acute  form  and  a  chronic  form  of  this  condition;  the  former 
is  more  intense  than  the  latter.     ''In  the  midst  of  perfect 

19 


290  SENSORY  NEUROSES 

euphoria,  a  feeling  of  intense  hunger  overcomes  the  patient, 
with  a  desire  to  satisfy  it.  This  hunger  sensation  is  associ- 
ated with  a  gnawing  feeling  in  the  stomach,  and  the  utmost 
fear  and  anxiety,  as  if  something  alarming  were  going  to 
happen.  If  the  feeling  of  hunger  is  not  satisfied  very 
quickly,  severe  headache  and  trembling  of  the  body,  or  even 
fainting  spells,  may  occur."  (Einhorn.)  The  attack  of 
bulimia  sometimes  yields  to  the  ingestion  of  a  small  amount 
of  food,  but,  as  a  rule,  large  quantities  have  to  be  taken. 

Treatment. — The  cause  of  this  condition  should  be  care- 
fully ascertained.  The  patient  should  partake  of  food 
during  the  attack ;  to  this  end  he  should  always  have  ready 
access  to  convenient  articles  of  food  or  drink,  as  crackers, 
zwieback,  chocolate,  or  milk. 

Efforts  have  been  made  to  influence  the  irritable  condi- 
tion of  the  "hunger  centre"  by  the  use  of  drugs.  Bromides 
in  large  doses,  1 .5  to  2  Gm.  (25  to  30  grains),  may  be  given 
tw^o  or  three  times  daily.  Boas  recommends  opium  with 
belladonna,  as  follows: 

Gm.  or  Cc. 

I^ — Extract!  opii, 

Extracti  belladonnse aa     0.01         gr.  f 

Sacchari 0.5         gr.  viiss 

Misce  et  ft.  chart  no.  i. 

Sig. — One  powder  to  be  taken  morning  and  night. 

Arsenous  acid,  0.001  Gm.  (i  grain),  in  pill  form,  or 
liquor  potassi  arsenitis,  may  be  administered.  Rosenthal 
recommends  extract  of  opium  hypodermically,  or  cocaine, 
0.03  to  O.Oo  Gm.  (^  to  1  grain),  twice  a  day.  Cocaine 
may  also  be  prescribed  in  the  following  form : 

Gm.  or  Cc. 

T^ — Cocaina;  hydrochloridi 0.1  gr.  iss 

Aqua;  amygdala^  aniarie 10.0  5iiss 

Misce. 

Sig. — Ten  drops  several  times  a  day. 

Gm.  or  Cc. 

I^ — Ammonii  bromidi, 

Sodii  bromidi afi       8.0  oij 

Aqua)  men  that!  piperita' 60.0  5ij 

Misce. 

Sig. — One  teaspoonful  twice  daily.     (Einhorn.) 


NERVOUS  ANOREXIA  291 

Gm.  or  Cc. 

I^ — Tincturaj  opii  camphoratis 90.0  3iij 

Tinctunc  belladonnae 1.0  Tllxv 

Elixiris  aroinatifi        .      ".      .      .     q.  s.  ad      180.0  gvi 

Misce. 

Sig. — One-half  fluidounco  three  times  a  day.     (Hemmeter.) 


AKORIA 

In  patients  suffering  from  akoria  the  normal  sensation  of 
satiety  is  lacking,  even  after  a  full  meal.  Patients  do  not 
know  when  they  have  eaten  enough.  There  may  be  no 
particular  desire  for  food,  however,  and  even  well-marked 
anorexia  may  be  present.  Akoria  is  found  in  connection 
with  such  conditions  as  give  rise  to  bulimia  or  polyphagia. 
Neurasthenics  and  hysterics  are  among  its  victims.  The 
treatment  should  consist  of  change  of  climate,  hyperalimen- 
tation, hydrotherapy,  electricity,  and  psychotherapeutics. 


NERVOUS  ANOREXIA 

"Nervous  anorexia"  is  a  term  used  to  designate  loss  of 
appetite  of  a  pronounced  and  chronic  nature.  There  exists 
on  the  part  of  the  patient  a  repugnance  to  every  kind  of 
food.  In  spite  of  this  fact,  the  functionating  powers  of  the 
stomach  and  intestine  are,  as  a  rule,  normal.  The  disease 
is  apparently  characterized  by  anesthesia  of  the  hunger 
''nerves."  Nervous  anorexia  is  always  a  symptom  of  such 
general  nervous  conditions  as  neurasthenia,  sexual  neuras- 
thenia, and  hysteria.  It  may  result  seriously,  from  lack  of 
proper  nourishment  to  the  body.  Among  the  exciting  causes 
are  frequently  found  great  mental  depression,  worry,  anxiety, 
and  fright. 

Treatment. — This  consists  in  maintaining  the  nutrition, 
if  need  be,  by  means  of  the  so-called  food  or  hyperahmenta- 
tion  cures.  Removal  of  the  patient  from  his  home  surround- 
ings must  be  considered  in  grave  cases.     Sometimes  it  is 


292  SENSORY  NEUROSES 

necessary  to  resort  to  nutritious  enemata  or  to  gavage.  In 
gavage,  or  feeding  by  the  stomach  tube,  such  nourishment 
as  milk,  eggs,  gruel  or  artificial  food  is  poured  into  the 
stomach  through  a  funnel  that  fits  into  the  external  end  of 
the  tube.  Care  must  be  exercised  not  to  cause  too  much 
distention  to  the  stomach,  unaccustomed  to  food  in  even 
ordinary  quantities,  until  tolerance  has  been  established. 

Stomachics,  such  as  orexin,  0.3  Gm.  (5  grains),  three  times 
a  day,  two  hours  before  meals,  and  cinchona  bark,  are 
indicated. 

Gm.  or  Cc. 

I^ — Decocti  cinchonse 10. Oto  180.0         5ijssto§\T 

Acidi  sulphuric!  diluti 0.3        TTl  v 

SjTupi  zingiberis     .  .       q.  s.  ad  200.0        S'^'ij 

Misce. 

Sig. — One  tablespoonful  three  times  a  day,  half  an  hour  before  meals. 

Gm.  or  Cc. 

I^ — Fluidextracti  cinchonse 60 . 0        §  ij 

Sig. — One-half  teaspoonful  three  times  a  day  in  a  wineglass  of  water,  to 
be  taken  before  meals. 

The  stomach  may  also  be  washed  out  with  water  in  which 
stomachics  have  been  incorporated.  Arsenic,  iron,  small 
doses  of  the  bromides,  and  strychnine  (0.001  to  0.002  Gm.) 
may  be  prescribed  as  occasion  requires.  Bernheim  has  used 
the  following  in  nervous  anorexia  with  marked  success: 

Gm.  or  Cc. 

I^ — Acidi  nitrohj'drochlorici 15.0  oSS 

Fluidextracti  nucis  vomicae 15.0  5ss 

Fluidextracti  taraxaci, 

Fluidextracti  gentiana; aa     30 . 0  5  j 

EUxiris  glycerophosphatum  compositi  .      .      .     60 . 0         5  ij 
Misce. 

Sig. — One  teaspoonful  in  one-quarter  of  a  glass  of  hot  water  three  times 
a  day,  half  an  hour  before  meals. 

Gm.  or  Cc. 
I^ — Tincturaj  nucis  vomica; 20 . 0  5  v 

Tinctura;  gentiana;  composita; 8.0  3ij 

Tinctura;  rhei  composita?, 

Aqua;  laurocerasi ail     20 . 0  o  v 

Aqua?  ment ha' piperita'  .  q.  s.  ad     00.0  oiij 

Misce. 
Sig. — One  tea-spoonful  in  wcnk  tea,  before  moals. 


GASTRIC  NEUROSES  AND  EYE  STRAIN  293 

Orexin  tannate  is  reported  to  have  been  productive  of 
good  effects  in  loss  of  appetite  from  purely  nervous  causes. 
The  usual  dose  in  anorexia  is  0.5  Gm.  (7^  grains)  twice  a 
day,  though  as  small  a  dose  as  0.1  to  0.2  Gm.(l|  to  3  grains) 
three  times  a  day  is  sometimes  prescribed  at  the  beginning 
of  the  treatment. 


GASTRIC  NEUROSES  AND  EYE  STRAIN 

The  medical  profession  are  indebted  to  Dr.  George  M. 
Gould  for  the  persistency  with  which  he  has  maintained 
that  many  of  the  so-called  gastric  neuroses  are  due  to  eye 
strain.  Nervous  dyspepsia  resulting  from  eye  strain  is 
characterized  by  such  symptoms  as  sick  headache,  anorexia, 
anemia,  and  many  types  of  malnutrition,  all  of  which  may 
be  due  to  astigmatism  or  anisometropia.  The  influence  of 
the  visual  organs  over  the  digestive  system  may  be  proved 
by  the  fact  that  a  normal  person  wearing  glasses  that  may 
be  worn  with  comfort  by  another  becomes  nauseated,  even 
to  the  point  of  vomiting.  There  is  no  truth  in  medical 
science  more  susceptible  of  demonstration  and  more  per- 
sistently ignored  in  daily  practice  than  the  immediate  asso- 
ciation of  eye  strain  and  malassimilation.  Clement  R.  Jones^ 
reports  four  cases  in  which  complete  relief  from  all  gastric 
symptoms  followed  the  correction  of  refractive  errors  and  the 
prescription  of  proper  lenses.  It  is  evident  (1)  that  neuras- 
thenia gastrica,  or  nervous  dyspepsia,  is  frequently  due  to 
or  compHcated  by  eye  strain;  (2)  that  other  gastric  disturb- 
ances are  sometimes  aggravated  by  eye  strain;  (3)  that 
along  with  other  points  in  the  examination  of  gastric  cases, 
careful  examination  of  the  visual  acuity  should  be  made; 
(4)  that  when  eye  strain  is  the  cause  of  gastric  symptoms, 
the  relief  by  proper  refraction  is  prompt  and  satisfactory. 

Musser  declares  that  ''the  correction  of  errors  of  refrac- 
tion  will   many   times   relieve   so-called   'bilious   attacks,' 

1  Lancet-Clinic,  July  18,  1908. 


294  SENSORY  NEUROSES 

periodic  vomiting,  anorexia,  indigestion,  and  other  gastric 
symptoms." 

According  to  Stockton -.^  "Commonly,  indeed  almost 
invariably,  the  etiology  of  the  trouble  (functional  disturb- 
ances of  digestion)  will  be  found  in  some  remote  and  perhaps 
unexpected  region  of  the  organism,  some  leak  of  general 
energy,  if  the  expression  is  permissible,  some  undiscovered 
irritation  of  the  nervous  system.  Thus  a  retroverted  uterus, 
proctitis,  or  a  displaced  kidney,  may  indirectly  lead  to  the 
important  disturbances  in  digestion,  but  more  frequent 
causes  of  gastric  asthenia  are  to  be  found  in  eye  strain. 
This  subject  has  been  so  widely  discussed  in  America  and 
from  so  many  points  of  view  that  it  is  somewhat  threadbare; 
yet  its  signal  importance  remains  largely  disregarded. 
Irregular  or  asymmetrical  astigmatism  is  the  visual  defect 
most  often  responsible  for  the  functional  disturbance,  but 
it  is  not  always  in  astigmatism  of  high  degree  that  the 
trouble  arises.  It  is  more  commonly  found  in  instances 
of  moderate  degree  of  astigmatism  with  axes  differing  in 
the  two  eyes,  and  especially  in  anisometropia.  Although 
not  limited  to  that  period  of  life,  the  nervous  disturbances 
following  these  visual  defects  are  apt  to  appear  after  the 
age  of  maturity,  and  are  especially  active  when  the  crystal- 
line lens  begins,  from  age,  to  lose  its  pliability." 

Gould,  after  prolonged  clinical  experience  and  study  of 
many  cases  of  digestive  disturbance,  declares  that  relief 
of  eye  strain  cures  a  host  of  the  disorders  of  digestion. 
Headaches  of  all  kinds,  sick  headaches,  migraine,  hemi- 
crania,  "rush  of  blood  to  the  head,"  the  commonest  and  most 
health- wrecking  of  all  diseases,  are  almost  always  due  to 
eye  strain.  My  personal  experience  confirms  the  belief  that 
eye  strain,  as  a  factor  in  gastric  disturbance,  must  not  be 
overlooked,  since  beneficial  results  are  obtained  as  soon  as 
the  errors  of  refraction  are  properly  corrected. 

'  Osier's  Modern  Medicine,  vol.  v,  p.  22. 


CHAPTER    XIII 

NERVOUS  DYSPEPSIA:    NEURASTHENIA  GASTRICA 

Von  Leube,  who  first  described  the  condition  designated 
nervous  dj'spepsia,  included  those  subjective  nervous  symp- 
toms which  were,  as  a  rule,  of  marked  intensity,  and  for 
which  it  was  impossible  to  find  cause  in  any  of  the  organic 
or  functional  disturbances  of  the  stomach.  It  was,  however, 
discovered  later  that  nervous  symptoms  of  a  like  nature 
present  themselves  in  disturbances  of  the  sensory,  secretory, 
and  motor  functions.  In  consequence  of  this,  the  term 
nervous  dyspepsia  is  applied  at  the  present  time  to  a  gastric 
neurosis  which  is  entirely  independent  of  functional  dis- 
turbances, and  is  of  purely  nervous  origin,  although  there 
may  be  coincident  disturbances  of  the  motor,  sensory,  or 
secretory  functions. 

Boas  says  that  nervous  dyspepsia  is  not  a  disease,  but  a 
symptom  complex,  in  which  organic  changes  connected 
directly  or  indirectly  with  the  digestive  organs  may  be 
present  and  not  detected,  or  may  be  absent.  Riegel,  on 
the  other  hand,  believes  that  nervous  dyspepsia  is  a 
combined  neurosis  in  which  subjective  symptoms — namely, 
sensory  disturbances  of  the  stomach — are  always  present. 
It  may  appear  as  an  independent  disease  and  as  an  inde- 
pendent neurosis. 

Etiology. — The  cause  of  nervous  dyspepsia  must  be  sought 
in  the  increased  irritability  of  the  sympathetic  nerves  of 
the  stomach.  This  heightened  irritability,  however,  shows 
itself  but  rarely  as  an  independent  affection.  The  class  of 
persons  apt  to  be  sufferers  from  this  condition  are  possessed 
of  a  more  or  less  irritable  and  unstable  central  nervous 
system.  They  are  spoken  of  as  being  of  a  nervous  disposi- 
tion.     In    such    persons    mental  emotions,   such  as  fright. 


296  NERVOUS  DYSPEPSIA 

sorrow,  care,  and  pathophobia,  often  act  as  an  exciting 
cause  of  actual  dyspeptic  conditions.  Nervous  dj'spepsia 
may  be  a  concomitant  of  diseases  of  other  organs,  particu- 
larly the  abdominal  viscera.  Constipation,  enteroptosis, 
helminthiasis,  often  induce  nervous  dyspepsia,  probably  by 
reflection  of  the  irritation  of  the  intestinal  sympathetic 
nerves  to  the  nerves  of  the  stomach.  Epigastric  hernia  is 
frequently  a  cause  of  this  neurosis;  as  are  also  diseases  of 
the  female  reproductive  organs,  such  as  anomalies  of  men- 
struation. During  the  menstrual  period  the  gastric  secretion 
is  often  hyperacid.  In  the  male,  sexual  excesses  are  not 
infrequently  responsible  for  nervous  dyspepsia.  Among 
the  etiologic  factors  must  also  be  mentioned  diseases  of 
such  remote  organs  as  the  lungs,  heart,  liver,  and  kidneys. 

It  has  long  been  recognized  that  patients  who  for  j^ears 
had  been  treated  for  nervous  dyspepsia  have  been  cured 
after  an  acute  attack  of  appendicitis  which  necessitated 
operation.  The  condition  of  the  appendix  had  not  been 
considered  in  connection  with  the  treatment  of  the  nervous 
dyspepsia.  The  medical  profession  has  been  slow  to  appre- 
ciate the  fact  that  stomach  symptoms  are  frequently  due 
to  chronic  appendicitis.  Unsuspected  gallstones  may  often 
produce  symptoms  of  nervous  dyspepsia.  A  sudden  attack 
of  gallstone  colic  draws  our  attention  to  the  gall-bladder; 
and  after  removal  of  the  offending  gallstones  the  stomach 
symptoms  entirely  disappear. 

There  is  a  vast  amount  of  preventable  suffering,  mani- 
fested by  general  ill  health,  vague  stomach  and  intestinal 
symptoms,  progressive  loss  of  flesh  and  strength,  obscure 
nervous  conditions,  anemia  and  obstinate  constipation, 
occasioned  by  chronic  appendicular  inflammation.^  The 
pathologic  condition  in  these  cases  is  often  due  to  a  slow 
proliferation  of  connective  tissue  in  the  walls  of  the  appendix. 
There  is  no  pus  formation,  and  it  maj^  be  months  or  years 
before  an  acute  attack  clears  up  the  diagnosis.  When  pain  is 
felt  in  these  cases,  it  is  often  not  in  the  region  of  the  appendix, 

'  Chronic  Appendicular  Inflammation,  New  York  Medical  Juuniai,  January 
13,  1906,  p.  94. 


NERVOUS  DYSPEPSIA  297 

over  the  McBurney  point;  it  may  be  more  generalized  about 
the  umbiHcus  or  be  referred  to  the  site  of  the  gall-bladder  or 
be  felt  in  the  stomach.  These  reflex  pains  are  not  surprising 
when  we  remember  the  abundant  connections  of  the  rich 
nerve  supply  of  the  appendix,  through  the  superior  mesen- 
teric plexus  of  the  sympathetic,  with  the  pneumogastric, 
hepatic,  and  gastric  plexuses.  These  cases  are  diagnosticated 
as  nervous  dyspepsia  and  are  treated  expectantly  and  symp- 
tomatically.  \^^len  the  physician  has  exhausted  his  patience 
and  resources  he  classes  these  patients  as  neurasthenics, 
and  is  likely  to  send  them  on  a  sea  voyage,  to  a  mineral 
spring,  or  to  a  sanatorium.  Many  such  cases  recover 
when  the  appendix  or  the  gallstones  are  removed.  Physi- 
cians should  be  on  the  alert  for  concealed  appendicitis, 
well  named  by  Ewald  ''appendicitis  larvata."  Obscure  as 
it  is,  the  true  diagnosis  will  often  be  reached  only  by  a 
process  of  exclusion. 

Kohn^  says  we  are  all  too  prone  to  call  diseases  we  cannot 
understand  ''nervous"  diseases,  for  want  of  a  better  term. 
A  more  honest  name  for  some  of  them  would  be  "diseases 
the  cause  of  which  we  do  not  know."  Appendicitis  larvata 
and  cholelithiasis  account  for  many  so-called  nervous 
dyspepsias.  Perhaps  as  our  knowledge  broadens  we  may 
eventually  be  able  to  account  for  the  remainder.  We  should 
endeavor  to  keep  clearly  in  mind  the  important  fact  that 
if  we  are  not  sure  the  symptoms  of  which  the  patient 
complains  are  purely  nervous  we  may  always  satisfy  our- 
selves, when  conditions  warrant,  by  the  relatively  harmless 
procedure  of  an  exploratory  laparotomy.  We  may  thereby 
save  the  patient  much  intense  suffering  without  endangering 
his  life. 

Symptoms. — Nervous  dyspepsia  gives  rise  to  a  variety  of 
symptoms,  some  of  which  are  general  in  character  while 
others  are  referable  particularly  to  the  stomach.  It  is  at 
times  a  difficult  matter  to  differentiate  between  symptoms  of 
purely  nervous  origin  and  those  which  have  an  organic  or 

^  Appendicitis  Larvata,  Surgery,  Gynecology,  and  Obstetrics,  October,  1906. 


298  NERVOUS  DYSPEPSIA 

functional  basis.  The  variety  and  variabilit\'  of  the  symp- 
toms, as  well  as  the  manner  in  which  the  patient  describes 
them,  are  characteristic  of  the  condition  present.  Often 
such  patients  are  free  from  distressing  symptoms  for  daj^s, 
or  even  weeks,  when,  owing  to  some  trivial  cause,  most  likely 
of  a  psychic  nature,  a  recurrence  of  the  sjmiptoms  takes 
place.  The  appetite  of  the  patient  is  apt  to  be  precarious: 
coarse  food  in  large  quantities  may  perhaps  be  partaken  of 
without  aggravation  of  the  symptoms,  while,  on  the  other 
hand,  certain  dietetic  articles  which  might  be  taken  with 
impunity  by  a  person  suffering  from  organic  disease  of  the 
stomach  are  rejected  as  ''not  agreeing"  with  the  patient. 

The  general  sjmiptoms  of  which  patients  suffering  from 
nervous  dj^spepsia  complain  are:  fulness  of  the  head, 
cephalalgia,  migraine,  inability  to  work,  vertigo,  lassitude, 
insomnia,  hypochondriac  and  melancholic  illusions.  Op- 
posed to  this  catalogue  of  subjective  symptoms  the  objec- 
tive symptoms  are  often  inconsiderable.  Patients,  as  a  rule, 
exhibit  the  well-known  neurasthenic  type.  The  condition 
of  nutrition  is  usually  good.  When  the  subjective  sj'mp- 
toms  become  severe,  there  is  at  times  a  diminution  in  weight, 
owing  to  the  refusal  of  the  patient  to  partake  of  adequate 
nourishment.  A  condition  of  genuine  inanition  may  develop. 
Palpation  of  the  stomach  often  elicits  hypersensibility  to 
pressure  over  the  celiac  plexus.  Cutaneous  hyperesthesia 
is  sometimes  found  over  the  region  of  the  stomach.  While 
all  this  is  present,  the  stomach  may  functionate  in  a  per- 
fectly normal  manner.  In  other  cases,  hyperacidity,  sub- 
acidity  or  achylia  may  be  present,  either  singly  or  in  com- 
bination with  atonic  conditions  of  the  stomach.  It  is  pathog- 
nomonic of  nervous  dyspepsia  that  well-marked  variability  in 
the  secretory  functions  sometimes  exists,  so  that  in  the  same 
patient  achjdia,  subacidity,  normal  acidity,  and  hyperacidity 
may  be  discovered  at  different  examinations — heterochylia 
(Hemmeter). 

The  physician  should  carefully  examine  the  entire  gastro- 
intestinal tract  in  every  instance  of  suspected  nervous 
dyspepsia  in  order  to  confirm  or  establish  his  diagnosis. 


NERVOUS  DYSPEPSIA  299 

Many  times  accurate  diagnosis  is  only  achieved  after  a 
prolonged  period  of  observation. 

Prognosis. — The  prognosis  for  a  complete  cure  without 
recurrence  is  not  favorable.  It  is  possible,  however,  under 
proper  treatment,  to  bring  about  marked  improvement 
in  the  condition  of  the  patient.  Riegel  never  saw  a  case 
that  terminated  fatally,  and  this  agrees  with  my  experience. 

Prophylaxis. — As  prophylaxis,  the  children  of  neurotic 
individuals  in  whom  the  habitus  enteroptoticus  is  well 
marked  should  be  kept  well  nourished  and  should  be  given 
gymnastic  exercises.  The  avoidance  of  excessive  mental 
exertion  is  an  important  prophylactic  measure. 

Treatment. — The  treatment  of  nervous  dyspepsia  per  se 
should  be  directed  toward  correcting  the  causes,  whatever 
they  may  be.  If  the  nervous  dyspepsia  is  secondary,  the 
primary  condition  should  receive  appropriate  treatment. 
The  subjective  symptoms  of  the  patient  yield  most  readily 
when  he  is  removed  from  his  customary  environment  and 
is  accorded  complete  rest  of  both  body  and  mind.  Marked 
benefit  has  resulted  in  some  cases  from  a  "six  weeks'  period 
of  absolute  rest.  During  the  rest  cure,  so  called,  the 
patient's  mind  should  be  occupied  as  little  as  possible. 
The  relationship  of  the  physician  and  patient  in  such  cases 
is  of  the  utmost  importance.  That  physician  will  have  the 
greatest  success,  other  things  being  equal,  who  knows  how 
to  gain  the  confidence  of  his  patient  and  is  able  to  exert 
an  influence  over  him.  Many  patients,  however,  owing  to 
domestic  or  financial  circumstances,  are  unable  to  leave 
their  home  surroundings.  Such  patients  should  be  kept 
in  the  recumbent  position  for  a  few  hours  during  the  morn- 
ing and  afternoon. 

The  question  of  nutrition  is  of  paramount  importance. 
The  diet  should  be  adapted  to  the  individual  case,  and 
greater  latitude  may  be  permitted  in  regard  to  varietj^  and 
quantity  than  in  cases  of  organic  gastric  disease,  since  the 
dyspeptic  symptoms  are  not  intimately  connected  with  the 
food  in  the  stomach.  An  effort  should  be  put  forth  to 
maintain  the  nutrition  of  the  patient  to  the  greatest  possible 
extent.     When  constipation  is  present,  coarser  foods  and 


300  NERVOUS  DYSPEPSIA 

foods  leaving  a  considerable  residue  are  indicated.  Even 
when  the  general  nutrition  is  normal  the  nervous  symptoms 
sometimes  disappear  after  a  course  of  hyperalimentation. 
When,  however,  well-marked  secretory  disturbances  are 
present,  the  diet  should  be  adapted  to  the  condition  of 
the  secretion.  Atonic  states  of  the  stomach  must  be  like- 
wise considered  in  prescribing  diet.  Patients  whose  symp- 
toms appear  synchronously  with  the  entrance  of  food  into 
the  stomach  should  receive  a  bland,  non-irritating  diet  at 
the  commencement  of  the  treatment,  to  be  gradually  changed 
to  one  of  a  more  solid  consistency.  \\Tien  an  aversion  or 
distaste  for  meat  exists,  other  protein  foods  must  be  substi- 
tuted. Sometimes,  however,  a  purely  vegetarian  diet  is  fol- 
lowed by  good  results.  When  meat  is  eliminated  from  the 
diet,  there  is  a  corresponding  diminution  of  gastric  secretion. 
To  supply  the  needed  stimulus  to  secretion,  meat  extracts 
may  be  prescribed.  The  meat-free  vegetarian  diet,  as 
sometimes  prescribed  in  gastric  diseases,  is  not  identical 
with  that  of  a  strict  vegetarian,  who  places  great  stress  on 
the  consumption  of  raw  fruits  and  vegetables.  A  vegetarian 
diet  proper  would  be  too  coarse,  too  voluminous  and  too 
poor  in  iron  for  patients  with  gastric  disease.  For  the  ner- 
vous dyspeptic  the  so-called  lactovegetable  diet  is  worthy  of 
consideration;  this  diet  includes  certain  animal  products, 
such  as  milk,  butter,  and  eggs.  Coarse  indigestible  food 
should  be  avoided  by  patients  suffering  from  nervous  dys- 
pepsia, and  the  diet  should  possess  as  high  a  nutritive  value 
as  possible  in  proportion  to  the  amount  ingested.  Such 
foods  as  radishes,  celery,  fresh  fruit,  nuts,  almonds,  dates, 
horseradish,  and  mushrooms  should  not  be  permitted  this 
class  of  patients.  These  food  articles  are,  however,  suitable 
to  dyspeptic  patients  suffering  from  constipation,  provided 
the  state  of  their  nutrition  is  good  and  their  symptoms  are 
not  associated  with  the  ingestion  of  food. 

In  prescribing  a  vegetarian  diet  the  physician  should  take 
into  consideration  the  individual  requirements  of  the  patient. 
While  green  vegetables  may  be  used  in  large  quantities,  they 
should  be  prepared  and  served  in  a  finely  divided  state  or  in 
the  form  of  puree.     Dry  vegetables  and  leguminous  flours 


NERVOUS  DYSPEPSIA 


301 


rich  in  protein  should  be  prescribed  in  Uberal  quantities. 
Flour  and  egg  dishes  in  the  form  of  puddings,  jam,  and  fruit 
juices  are  well  borne  by  the  nervous  dyspeptic.  The  unfer- 
mented  juice  of  grapes,  possessing  a  comparatively  high  nu- 
tritive value,  is  a  suitable  beverage.  Of  baked  foods,  wheat 
bread,  zwieback,  rusks,  biscuits,  and  brown  bread  may  be 
prescribed. 

The  protein  in  lactovegetable  diet  may  be  supplied  in  the 
form  of  eggs,  milk,  and  cheese;  the  fat  constituent  of  such 
diet  is  derived  from  butter,  oil,  milk,  and  cream.  Milk 
should  be  fed  to  this  class  of  patients  in  large  quantities,  pure, 
or  as  buttermilk,  sour  milk,  kefir,  or  Yoghurt  milk  (see  p. 
93) .  Yoghurt  milk  is  said  to  possess  the  power  of  lessening  the 
decomposition  process  in  the  intestinal  tract.  In  prescribing 
a  lactovegetable  diet  the  condition  of  the  gastric  secretion 
should  be  closely  studied.  In  order  to  assist  the  patient  in 
maintaining  a  fair  appetite,  monotony  in  the  articles  of  food 
prescribed  should  be  avoided.  Of  beverages,  tea  is  preferable 
to  coffee.     Alcoholic  drinks  should  be  avoided  entirely. 


Lactovegetable  Diet  List  (Wegele) 


Morning 


Forenoon 


Noon 


Afternoon 


Evening 


250  Gm.  milk  cocoa 
100  Gm.  rolls    .      .      . 
30  Gm.  butter       .      . 
250  Gm.    milk    pap    with 

white  of  egg 
250  Gm.   vegetables   with 

rice  .... 
250  Gm.  pudding  . 
150  Gm.  apple  sauce  . 
250  Gm.  milk  cocoa  . 
100  Gm.  rolls  .  .  . 
30  Gm.  butter  .  . 
200  Gm.  gruel  with  yolk  of 

egg    ...      . 

200  Gm.  water  noodles 

125  Gm.  plums 

100  Gm.  rolls    .      .      . 

30  Gm.  butter       .      . 


Protein. 

9.0 
9.0 
0.5 

12.0 

5.0 
15.0 

3.0 
9.0 
0.6 

3.5 
5.0 
0.4 
9.0 
0.6 

81.6 


Fat. 

10.0 

1.0 

24.6 

8.0 

18.0 
25.0 

10.0 

1.0 

24.6 

7.5 
1.5 

1.0 
24.6 

1.56.8 


Carbohydrate. 

72.50 

58.00 

0.15 

11.00 

20.00 
50.00 
20.00 
72.50 
58.00 
0.15 

18.00 
40.00 

8.30 
58.00 

0.15 


486 . 75 


Calories 300.0 

Total  combustion  value,  3660  calories. 


1300.0         2060.00 


302  NERVOUS  DYSPEPSIA 

Physical  Treatment. — Hydrotherapeutic  measures  are 
indicated  for  the  general  nervous  condition  which  charac- 
terizes patients  suffering  from  nervous  dyspepsia.  These 
measures  consist  of  cool  rubbings,  half  baths,  cool  douches, 
and  cold  baths.  The  Scotch  douche,  alternate  cold  and  hot 
applications,  may  be  used  locally  over  the  region  of  the 
stomach.  Patients  whose  state  of  nutrition  is  good  should 
be  persuaded  to  persevere  in  gymnastic  exercises;  those  in  a 
run-down  condition  should  not  undertake  exertion  of  any 
kind  before  the  condition  of  their  nutrition  has  improved. 
Massage,  including  vibratory  treatment,  may  be  instituted 
for  the  purpose  of  stimulating  tissue  metamorphosis;  it  may 
include  the  whole  body  or  simply  the  stomach  or  abdomen. 
Electric  treatment,  galvanic  or  faradic,  of  the  stomach  and 
intestine,  may  be  used  with  advantage. 

Rose  reports  excellent  results  from  the  application  of  his 
plaster  belt  (Fig.  32).  Whenever  gastroptosis  or  entero- 
ptosis  is  a  complication  in  gastric  neurosis,  the  treatment 
indicated  for  those  conditions  and  described  in  detail  in 
Chapter  X  should  be  instituted. 

Mineral  Waters. — Mineral  water  cures  are  contraindicated 
in  perhaps  the  majority  of  cases  of  gastric  disease  of  purely 
nervous  origin.  In  nervous  dyspepsia  resulting  from 
chlorosis  and  anemia  the  ferruginous  mineral  waters  may 
be  prescribed.  The  ferro-arsenous  waters  of  Levico  and 
Roncegno  are  indicated  in  cases  of  anemia.  Among  other 
springs  of  this  class  may  be  mentioned  Harbin,  Hot  Sulphur 
Springs,  Crockett  Arsenic  Lithia  Springs,  and  Swineford 
Arsenic  Lithia  Springs. 

One  liter  of  the  iron-arsenic  waters  contains  the  following 
quantities  (grammes)  of  iron  sulphate,  arsenic  acid,  and 
arsenous  salts: 

Iron  .siilpli;ito.  Arspiiic  acid.  ArsetKHis  salts. 

Crockett  Arsenic  Lithia  Springs    .         O.OOOG         ().()()(W 


Gucberquellc  (Srebernik)    .      .      .  0.3700  0 

Harbin  Hot  Sulphur  Springs    .      .  0.0300  0 

Lausigk 4.1800  0 

Levico 2.5000  0 

Recoaro 3.2()()0  0 

Roncegno      3.0000  0 


(HKil  o.ooo;? 

0(){)1  ().0().")0 

0001  O.OOoO 

OOSG  O.OOoO 

003'.)  0.0050 

1500  0.0050 


NERVOUS  DYSPEPSIA  303 

Sea  Water  Therapy. — Good  results  have  frequently  been 
obtained  from  the  subcutaneous  injection  of  sea  water  in  the 
treatment  of  cases  of  nervous  dyspepsia  of  obscure  origin. 
The  results,  if  beneficial,  are  apparent  soon  after  beginning 
the  treatment.  It  has  been  clinically  demonstrated  that 
sea  water  plasma  is  a  powerful  tonic  to  the  nervous  system. 
It  stimulates  metabolism  to  such  a  degree  that  the  appetite 
improves  and  there  is  an  increase  in  the  body  weight. 
The  water  relieves  pain,  allays  nervous  irritability,  and 
induces  restful  sleep;  there  is  a  general  improvement  in 
tone  throughout  the  entire  nervous  system,  and  the  bowels 
move  regularly. 

The  therapy  of  sea  water  depends  upon  Quinton's  law 
of  marine  constancy:^  '^ Animal  life,  which  appears  as  a 
cell  in  seas  of  well-determined  saline  concentration,  in  order 
to  maintain  its  optimum  cellular  activity  has  always  a 
tendency  throughout  the  zoological  scale  to  keep  the  cells 
of  which  each  organism  consists  in  the  aquatic  marine 
conditions  of  their  origin." 

Geology  and  paleontology  agree  in  admitting  that  animal 
life  first  appeared  in  the  sea,  and  the  analysis  of  the  blood 
serum  and  ash  of  every  animal  entering  into  the  zoological 
series  shows  that  the  mineral  composition  of  the  medium 
necessary  to  cellular  life  is  the  same  as  that  of  the  original 
seas.  It  is  from  these  facts  that  Quinton  deduces  his  novel 
conception  of  the  animal  organism  as  an  actual  sea  aquarium 
in  which  the  cells  of  which  it  is  composed  continue  to  live 
under  the  aquatic  conditions  of  their  origin. 

Having  shown  that  the  primordial  seas  contained  only 
0.8  per  cent,  of  salts,  it  is  necessary,  in  order  to  produce 
a  plasma  of  that  strength,  to  dilute  the  sea  water  of  the 
present  day,  which  contains  3.3  per  cent,  salts.  For  the  pur- 
pose of  diluting,  pure  spring  water  containing  a  minimum  of 
mineral  and  free  from  bacteria  is  used  in  the  proportion  of 
two  parts  of  sea  water  to  five  of  spring  water.  Great  care 
must  be  observed  in  collecting  the  sea  water  in  order  to 

'  International  Medical  Annual,  1910,  p.  98. 


304 


NERVOUS  DYSPEPSIA 


Fig.  39 


avoid  accidental  impurities.  It  should  be  obtained  not  less 
than  twenty  miles  from  any  port  or  stream  flowing  from  a 
port,  and  at  a  depth  of  not  less  than  ten  meters.    The  water 

must  be  fresh,  three  weeks  being 
the  limit  of  time  which  should 
elapse  between  its  collection  and 
injection.  After  dilution  as  above 
it  should  be  filtered  through  a 
porcelain  filter  of  the  Pasteur 
type.  Every  precaution  for  the 
sterilization  of  vessels  should  be 
observed,  but  the  water,  aside 
from  the  care  in  handling  and 
filtering  as  above,  is  not  to  be 
sterilized  further,  or  it  will  be 
rendered  therapeutically  useless. 
After  filtering  the  water  it  may 
be  put  in  flasks  or  ampoules  of  a 
capacity  of  30,  50,  100  Cc.  or 
more,  as  the  convenience  of  the 
operator  may  require. 

The  injection  is  performed  with 
a  rubber  tube  1.5  meters  in  length, 
and  ending  in  a  platinum-iridium 
needle  3  centimeters  long;  this 
latter  should  be  protected  by  a 
glass  tube,  T  (Fig.  39) .  The  tube 
and  needle  must  be  boiled  before 
connecting  with  the  ampoule. 
The  connection  is  made  as  fol- 
lows :  (1)  File  the  lower  end  of  the 
straight  tube,  A,  of  the  ampoule, 
break  its  ])oint  and  join  it  to  B, 
the  free  end  of  the  rubber  tube. 
(2)  File  the  end  of  the  bent  tube  C,  break  its  point,  and  hang 
up  the  ampoule  by  the  bend  in  the  tube  at  D,  about  one 
meter  above  the  patient.  To  start  the  flow,  the  bulb  of 
a  thermocautery   attached    to   the  end  C  is  useful.     It  is 


Apparatus  for  the  injection  of  sea 
water. 


NERVOUS  DYSPEPSIA  305 

advisable  to  interrupt  the  tube  of  the  bulb  by  a  glass  tube 
packed  with  sterilized  absorbent  cotton  to  filter  the  air. 
(3)  The  ampoule  being  hung  uj),  remove  the  tube  T  and  allow 
the  fluid  to  run  until  the  rubber  tube  is  quite  empty  of  the 
boiled  water  and  the  air  it  contains.  Make  sure  it  is  salt 
water  that  is  running  by  tasting  drops  on  the  back  of  the 
hand  periodically^     Then  stop  the  flow  with  the  clip  F. 

The  best  point  for  injection  lies  behind  the  great  tro- 
chanter. After  the  skin  has  been  cleansed  with  alcohol  the 
needle  should  be  driven  its  w^hole  length  at  right  angles 
to  the  skin  surface,  except  in  very  thin  persons.  If  this 
should  cause  pain,  withdraw  the  needle  a  few  millimeters. 
Subsequent  injections  should  be  made  in  the  same  location, 
to  avoid  a  repetition  of  the  pain  which  may  arise  twelve 
hours  after  the  first  injection  from  stretching  of  the  tissues. 
After  injection  the  needle  wound  should  be  covered  for  a 
minute  or  two  with  a  pledget  of  cotton  soaked  in  alcohol; 
it  will  have  closed  up  by  that  time. 

The  quantity  of  sea  water  injected  is  of  great  importance. 
It  is  advisable  to  start  with  20  or  25  Cc.  every  other  day. 
There  should  be  no  rise  of  temperature  or  other  symptom  of 
reaction.  If  symptoms  of  malaise  appear,  the  dose  must  be 
decreased;  if  there  is  no  reaction,  it  should  be  increased 
to  50  Cc.  as  soon  as  possible  and  be  given  every  other  day. 
The  injections  may  be  given  at  any  time  of  the  day.  During 
the  treatment  all  antiseptics  by  mouth  should  be  discon- 
tinued. Lavage  of  the  stomach  must  not  be  employed. 
The  treatment  need  not  cease  on  account  of  menstruation. 
When  the  treatment  is  well  tolerated  the  dyspeptic  symp- 
toms diminish  progressively  and  recovery  is  brought  about 
after  a  course  of  thirty  or  forty  injections. 

Drug  Treatment. — Drug  treatment  occupies  an  important 
place  in  the  treatment  of  this  type  of  dyspepsia.  The  tonics, 
stomachics,  sedatives,  and  hypnotics  are  all  valuable.  ^Yhen 
nervous  irritability  is  marked,  the  bromides  may  be  pre- 
scribed. Chloral  hydrate  in  small  doses,  0.1  to  0.3  Gm. 
(li  to  5  grains),  may  be  prescribed,  to  be  taken  three  or 
four  times  a  day.     Insomnia  may  be  combated  by  veronal, 

20 


306  NERVOUS  DYSPEPSIA 

trional,  or  chloral  hydrate,  the  last  in  the  dose  of  2  to  3  Gm. 
(30  to  45  grains)  per  rectum  in  a  mucilaginous  vehicle. 
Deficient  appetite  calls  for  bitters  and  stomachics.  Boas 
recommends,  in  cases  of  neurosis  having  an  anemic  basis, 
the  following: 

Gm.  or  Cc. 

I^ — Ferri  bromidi, 

Quininae  hydrobromidi aa     4.00         5j 

Extract!  rhei q.s. 

Misce  et  ft.  pil.  no.  c. 

Sig. — Two  pills  three  times  a  day. 

When  constipation  is  a  comphcation  it  should  be  treated 
by  other  means  than  purgatives,  A  diet  should  be  pre- 
scribed which  leaves  large  residues  in  the  bowels;  abdominal 
massage,  faradization  of  the  rectum  and  abdomen,  and 
enemata  in  which  oUve  oil  or  cottonseed  oil  has  been  incor- 
porated, will  usually  serve  to  counteract  the  constipation. 

Glycerophosphates  and  lecithin  have  been  used  with 
marked  success  in  the  treatment  of  nervous  dyspepsia. 
The  glycerophosphates  are  the  salts  of  glycerophosphoric 
acid.  They  are  said  to  be  "nerve  foods"  and  "nerve 
tonics,"  on  the  theory  that  the  phosphorus  they  contain 
approximates  more  nearly  to  lecithin  than  the  phosphorus 
constituent  of  the  hypophosphites,  and  is  assimilated 
more  readily.  In  addition  to  the  present  official  elixir  con- 
taining the  glycerophosphates  of  sodium  and  calcium,  a 
compound  elixir  containing  the  glycerophosphates  of 
calcium,  sodium,  iron,  manganese,  quinine,  and  strychnine 
is  largely  used.  The  lecithins  are  preparations  of  both 
animal  and  vegetable  origin.  They  are  esters  of  fattj'  acids 
and  glycerophosphoric  acid  in  combination  with  protein. 
Animal  lecithin  is  found  chiefly  in  nerve  and  brain  tissue, 
for  which  reason  it  has  been  designated  a  "nerve  food." 
It  acts  as  a  stimulant  to  nutrition  rather  than  as  a  direct 
nutrient.  Even  in  large  doses  these  preparations  are  non- 
toxic. Many  of  the  animal  extracts  put  up  b}^  large  meat- 
packing houses  also  contain  lecithin.  The  glycerophos- 
phates and  lecithin  in  various  combinations  are  placed 
before  the  profession  in  ampoule  form,  and  may  be  adminis- 


NERVOUS  DYSPEPSIA  307 

tered  hypodermically,  together  with  the  iron  and  arsenic 
preparations  described  on  page  240.  Cacodylate  of  sodium 
hypodermically,  0.05  Gm.  (1  grain),  has  proved  of  great 
value  in  my  work.  I  give  this  preparation  once  a  day  for 
four  weeks.  It  is  a  great  stimulant  to  metabolism,  and  so 
affects  nutrition  as  to  bring  about  marked  improvement  in 
general  nervous  conditions. 

Menthol  has  proved  valuable  in  the  treatment  of  nervous 
dyspepsia.  The  pain,  vomiting,  anorexia,  or  flatulence  often 
subsides  at  once,  and  permanent  relief  results.  It  should 
be  prescribed  in  the  dose  of  0 . 3  Gm.  (5  grains) ,  three  times 
a  day.    It  can  be  advantageously  combined  with  the  alkalies. 

The  author  has  found  the  following  prescriptions  of  value 
in  the  medicinal  treatment  of  nervous  dyspepsia: 

In  cases  of  hypersecretion: 

Gm.  or  Cc. 
I^ — Extracti  belladonnse  foliorum   ....         0.5  gr.  viiss 

Magmae  magnesiae    .      .      .      .       q.  s.  ad     120.0  giv 

Misce. 
Sig. — Teaspoonful  three  times  daily,  a  quarter  of  an  hour  before  meals. 

In  cases  of  fermentation  add  resorcinol : 

Gm.  or  Cc. 

I^ — Resorcinolis 6.0  3iss 

Extracti  belladonnse  foliorum   ....         0.5  gr.  viiss 

Magmae  magnesiae    .      .      .      .       q.  s.  ad     120.0  5iv 

Misce. 

Sig. — Teaspoonful  three  times  a  day,  a  quarter  of  an  hour  before  meals. 

In  cases  of  excessive  acidity: 

Gm.  or  Cc. 

I^ — Sodii  bicarbonatis 60.0  §ij 

Sig. — Teaspoonful  in  a  half-glass  of  water,  one  hour  after  meals. 

In  cases  of  constipation  with  excessive  acidity: 

Gm  or  Cc. 

I^ — Magnesii  oxidi 20.0  3v 

Sodii  bicarbonatis 60 . 0  5  ij 

Misce. 

Sig. — Teaspoonful  in  a  half-glass  of  water,  one  hour  after  meals. 


308  NERVOUS  DYSPEPSIA 

In  cases  of  diarrhea  with  excessive  acidity: 

I^ — Bismuthi  subcarbonatis,  Gm.  or  Cc. 

Cretae  prajparatae, 

Pulveris  ossis aa      30 . 0  §  j 

Misce. 

Sig. — Teaspoonful  in  water  one  hour  after  meals. 

In  cases  of  subacidity  the  following  bitter  tonics : 

Gm.  or  Cc. 

I^ — Tincturae  nucis  vomicae 8.0  3ij 

Tincturae  cinchonae  compositae        q.  s.  ad       90.0  Siij 

Misce. 
Sig. — Teaspoonful  three  times  a  day,  before  meals. 

Gm.  or  Cc. 
I^ — Tin cturse  gentianse  compositae        .      .      .       60.0  5ij 

Sig. — Teaspoonful  in  water  three  times  a  day,  before  meals. 

In  cases  of  deficient  hydrochloric  acid : 

Gm.  or  Cc. 
I^— Acidi  hydrochlorici  diluti 120.0  giv 

Sig. — Fill  No.  "00"  double  capsule  and  take  four  such  with  water,  at 
intervals  of  ten  minutes,  after  each  meal. 

Gm.  or  Cc. 

I^— Glyceriti  pepsini,  N.  F 240.0  oviij 

Sig. — Tablespoonful  in  water  during  meals. 

In  cases  of  impaired  motility: 

Gm.  or  Cc. 

I^— Strychninae  sulphatis 0 .  003  gr.  ^V 

Ft.  pil.  vel  tab.  no.  i. 

Sig. — One  three  times  a  day,  before  meals. 

Many  cases  of  nervous  dyspepsia  may  require  surgical 
intervention,  and  our  attention  must  always  be  given  to  the 
possible  presence  of  gallstones  or  chronic  appendicitis. 
Mayo  has  repeatedly  called  attention  to  the  frequency 
with  which  chronic  appendicitis  is  associated  with  gastric 
symptoms.  It  is  now  definitely  established  that  appen- 
dicular disease  does  produce  definite  gastric  symptoms,  a 
condition  for  which  Paterson'  suggests  the  tonii  "appen- 
dicular gastralgia." 


NERVOUS  DYSPEPSIA  309 

Clinical  experience  presents  strong  evidence  that  there 
are  gastric  disturbances  which  are  relieved  or  even  com- 
pletely dissipated  by  removal  of  the  appendix.  Examination 
of  the  appendices  removed  in  association  with  gastralgia, 
pylorospasm,  gastric  and  duodenal  ulcers-,  cholecystitis, 
and  cholehthiasis,  shows  that  there  is  a  higher  percentage 
of  appendices  with  partially  or  completely  obliterated 
lumina  in  all  of  these  conditions  than  at  general  autopsy 
or  at  operations  for  appendicitis.  MacCarty  and  McGrath^ 
found  that  of  365  patients  in  whom  cholecystectomy 
was  performed,  13  per  cent,  gave  definite  histories  of 
pain  and  soreness  in  the  region  of  the  appendix.  In  59 
of  these  patients  with  cholecystitis  the  appendices  were 
removed  and  69  per  cent,  showed  undoubted  gross  or  micro- 
scopic evidence  of  inflammation,  varying  from  a  chronic 
catarrhal  condition  to  complete  obliteration  and  peri- 
appendicitis. 

Fenwick'^  states  that  frequently  the  character  of  the 
trouble  in  the  appendix  is  indicated  by  the  character  of  the 
gastric  secretion,  an  active  irritation  being  indicated  by 
hypersecretion,  while,  on  the  other  hand,  torsion,  thickening, 
cystic  dilatation,  or  adhesion  is  followed  after  a  time  by 
a  type  of  chronic  gastritis  characterized  by  flatulence, 
nausea,  anorexia,  excess  of  mucus,  and  absence  of  free 
hydrochloric  acid.  He  says  that  a  continuous  flow  of  hyper- 
acid gastric  juice,  reflexly  produced  by  disease  of  some 
other  organ — the  appendix,  pancreas,  gall-bladder,  tubercu- 
losis or  neoplasm  of  the  cecum — always  excites  severe 
inflammation  of  the  stomach,  and  is  liable  to  be  followed  by 
ulcer  of  that  organ  or  of  the  duodenum.  It  also  sooner  or 
later  gives  rise  to  spasm  of  the  pylorus,  causing  pain  and 
intermittent  obstruction  which  may  lead  to  a  diagnosis 
of  cancer, 

Frgm  a  careful  study  of  271  cases  of  achlorhydria  gastrica 
hsemorrhagica,  with  a  complex  of  gastric  symptoms,  Pilcher^ 

1  Lancet,  January  14,  1911,  p.  97. 

2  Journal  of  the  American  ^Medical  Association,  January  7,  1911. 

■*  Dyspepsia  and  the  Prophylaxis  of  Cancer  of  the  Stomach,  Journal  of  the 
American  Medical  Association,  November  26,  1910,  p.  1896. 


310  NERVOUS  DYSPEPSIA 

found  that  in  156  cases  the  onset  seemed  to  bear  an  immedi- 
ate and  direct  relation  to  various  diseases.  In  100  of  these 
patients  operated  on,  the  trouble  in  36  was  found  to  be 
due  to  appendicitis,  in  32  to  gall-bladder  trouble,  in  16  to 
gall-bladder  and  pancreatic  disease  combined,  in  12  to 
appendicitis  and  gall-bladder  involvement  combined,  and 
in  16  the  stomach  alone  was  found  diseased.  In  24  there 
was  pylorospasm — in  18  with  appendicitis  and  in  6  with 
gall-bladder  involvement.  The  achlorhydria  is  attributed  to 
reflex  inhibition  of  gastric  secretion  by  disease  elsewhere 
than  in  the  stomach.  From  this  it  would  seem  that  hyper- 
secretion and  hyposecretion  of  hydrochloric  acid  may  be  due 
to  the  same  remote  causes  in  different  patients. 

'  Absence  of  Hydrochloric  Acid  with  Blood  in  the  Stomach  Secretion 
(Achlorhydria  Hsemorrhagica  Gastrica)  as  a  Symptom  of  Chronic  Gastritis, 
Journal  of  the  American  Medical  Association,  November  19,  1910,  p.  1790. 


CHAPTER    XIV 

SECRETORY  NEUROSES:  HYPERACIDITY— HYPERCHLOR- 
HYDRIA— SUPERACIDITY 

HYPERCHLORHYDRIA 

The  term  ''hyperchlorhydria"  is  applied  to  that  condition 
of  the  gastric  secretions  in  which  the  quantity  of  gastric 
juice  is  normal  but  the  percentage  of  free  hydrochloric  acid 
higher  than  normal.  The  hyperacid  gastric  juice  is  secreted 
during  digestion  only,  from  the  stimulus  of  food  in  the 
stomach.  Many  writers,  especially  those  who  follow  the 
teachings  of  Pawlow,  maintain  that  hyperacidity  is  not  a 
clinical  entity,  but  merely  one  aspect  of  hypersecretion. 
They  claim  that  there  is  no  increase  in  the  percentage  of 
free  hydrochloric  acid  in  the  gastric  juice,  but  only  an 
increase  in  the  quantity  of  the  secretion  itself,  the  constit- 
uents being  normal  in  amount.  This  view  is  in  opposition 
to  a  convincing  array  of  clinical  facts  and  observations; 
we  are  justified  in  looking  upon  hyperacidity  as  a  condition 
entirely  independent  of  hypersecretion. 

Hyperacidity  is  primarily  a  disturbance  of  the  gastric 
function  in  which  the  mucous  membrane  of  the  stomach, 
under  the  stimulus  of  food,  secretes  gastric  juice  containing 
an  excessive  amount  of  free  hydrochloric  acid.  It  may  be 
of  purely  nervous  origin,  a  secretory  neurosis  dependent  upon 
the  abnormal  stimulation  or  inhibition  of  certain  nerve 
trunks  leading  to  the  stomach.  This  variety  of  hyper- 
acidity is  the  one  most  frequently  observed.  It  is  not  always 
possible  to  draw  a  distinct  line  between  the  two  varieties, 
neurotic  and  organic ;  so  they  may  be  considered  together. 
These  forms  of  hj^jeracidity  are  designated  genuine,  in 
contradistinction    to     those    which    occur    secondarily    as 


312  SECRETORY  NEUROSES 

sequelae  of  other  pathologic  processes.  Hyperacidity  in 
gastritis  chronica  (gastritis  acida)  or  ulcus  ventriculi  may 
be  either  secondarj^  or  primary — the  result  or  the  cause. 
The  cUnical  sjonptoms  characteristic  of  hyperacidity  are 
sometimes  misleading;  the  symptoms  may  be  present  when 
the  gastric  juice  is  of  normal  acidity,  as  shown  by  examina- 
tion after  a  test  meal,  or  they  may  be  absent  when  the  test 
shows  a  marked  hyperacidity.  The  presence  or  absence 
of  subjective  symptoms  is  doubtless  due  to  a  difference  in 
the  sensibihty  of  the  gastric  mucous  membrane.  Accord- 
ing to  Riegel,  hyperacidity  has  to  be  viewed,  in  the  majority 
of  cases,  as  a  constitutional  anomaly.  Dalton  holds  that 
hyperacidity  of  the  contents  of  the  duodenum,  due  to  the 
hyperacid  condition  of  the  stomach,  produces  derangement 
of  physiologic  metabohsm,  and  is  the  starting-point  of  nearly 
all  skin  diseases  except  the  contagious  exanthemata. 

Etiology. — Hyperchlorhydria  is  of  very  frequent  occurrence. 
From  the  studies  of  Riegel,  Reichmann,  Jaworski,  Glusinski, 
and  Ewald  we  learn  that  in  almost  50  per  cent,  of  all  patients 
suffering  from  digestive  disorders,  acidity  of  the  gastric 
juice  is  rather  increased.  Einhorn  states  that  hyperchlor- 
hydria is  present  in  more  than  half  the  ''digestive"  cases. 
It  is  a  disease  of  both  sexes.  TMiile  it  is  met  with  chiefly  in 
adults,  neither  the  3'oung  nor  the  old  are  exempt.  Persons 
of  a  nervous  temperament,  those  suffering  from  neuras- 
thenia, hypochondria,  or  melancholia  are  apt  to  be  its 
victims.  Hyperchlorhydria  has  followed  grief,  worry,  and 
mental  overwork.  In  the  majority  of  cases  the  cause  is 
psj'chologic.  Bad  habits  of  eating,  the  quick-lunch  counter, 
insufficient  mastication  of  food,  beverages  either  too  hot 
or  too  cold,  coffee,  alcohol,  tobacco,  the  habit  of  taking 
highly  spiced  dishes,  all  predispose  to  hyperchlorhj'dria. 
It  freciuently  accompanies  ulcus  ventriculi  and  constipation. 
In  chlorosis  and  cholehthiasis,  hyperchlorhydria  has  been 
noted,  but  the  causal  connection  of  these  diseases  is  by  no 
means  clear. 

Pathology. — No  characteristic  pathologic  changes  have  been 
found  in  the  few  cases  in  which  postmortem  has  been  made. 


IIYPERCHLORHYDRIA  313 

Symptoms. — Hyperchlorhydria  develops  gradually.  At  first 
the  patient  experiences  an  uneasy  sensation  one  or  two 
hours  after  dinner.  Later  this  feeUng  becomes  aggravated 
into  one  of  distress  occurring  from  one  to  three  hours  after 
each  meal.  The  subjective  discomforts  of  the  patient  set 
in  at  the  height  of  digestion,  during  which  time  the  acid 
secretion,  and  especially  hydrochloric  acid,  greatly  exceeds 
the  normal.  The  degree  of  discomfort  at  this  time  does  not 
depend  upon  the  quantity  of  acid  so  much  as  upon  the  sen- 
sitiveness of  the  gastric  mucosa.  Low  degrees  of  hj^per- 
acidity  sometimes  provoke  painful  symptoms.  The  pain 
may  last  for  an  hour  or  two,  or  longer,  and  then  disappear. 
Patients  are  frequently  able  to  predict  the  exact  time  the 
pain  or  distress  is  likely  to  occur.  The  pains  y&vj  not  only 
in  duration,  but  in  severity,  from  mild  distress  to  violent 
cramping  seizures  caused  by  obstruction  to  the  outflow  of 
the  acid  contents,  together  with  violent  peristaltic  move- 
ments of  the  stomach,  iittacks  of  the  maximum  severity 
occur  comparatively  seldom.  Patients  are,  as  a  rule,  able 
to  ease  their  pains  by  partaking  of  some  article  of  food, 
such  as  the  white  of  an  egg,  rich  in  albumin.  Besides  the 
gastric  pain,  there  are  very  often  severe  headaches  and 
vertigo.  Constipation  is  common.  The  victims  of  hyper- 
chlorhydria do  not  usually  produce  the  impression  on  the 
observer  of  being  very  sick.  They  appear  to  be  well  nour- 
ished, except  in  cases  where  faulty  and  insufficient  diet  has 
been  maintained  for  a  long  time. 

Objective  Symptoms. — During  the  painful  attacks  the  region 
of  the  stomach  is  distended  and  sensitive  to  pressure.  A 
splashing  sound  can  be  obtained  after  the  ingestion  of  water, 
or  after  meals,  but  not  when  the  stomach  is  empty. 

Diagnosis. — The  diagnosis  is  confirmed  only  by  examina- 
tion of  the  stomach  contents.  What  remnants  of  food  are 
found  appear  finely  divided  and  well  digested.  The  tests 
for  free  hydrochloric  acid  are  positive.  Clinicians  calculate 
the  normal  total  acidity  after  a  test  breakfast  to  be  40  to 
60;  in  hyperacidity  the  total  acidity  is  75  to  80.  A  total 
acidity  of  160  has  been  recorded.     It  is  important  to  ascer- 


314  SECRETORY  NEUROSES 

tain  the  quantity  of  free  hydrochloric  acid  in  every  case. 
A  disk  of  coagulated  egg  albumin  placed  in  the  filtrate  of 
the  gastric  contents  will  become  digested  in  a  short  time. 
Gastric  contents  obtained  three  or  four  hours  after  the  test 
meal  show  that  meat  has  been  entirely  digested,  while  starches 
are  but  slightly  changed.  According  to  Einhorn,  the  fil- 
trate of  gastric  contents  after  either  a  test  dinner  or  a  test 
breakfast  shows  the  presence  of  starch  or  large  quantities 
of  erythrodextrin.  The  addition  of  a  few  drops  of  Lugol's 
solution  to  the  filtrate  will  produce  either  a  blue  color  or 
an  intense  dark  red.  The  presence  of  the  unaltered  or 
slightly  altered  starches  is  due  to  the  fact  that  hydrochloric 
acid  begins  to  be  secreted  directly  after  the  ingestion  of 
food,  and  amylolysis  is  thus  interrupted. 

Prognosis. — Hyperchlorhydria  or  hyperacidity  may  yield 
to  appropriate  treatment.  The  prognosis  is,  as  a  rule,  good, 
except  in  some  very  protracted  and  severe  cases.  Should 
there  be  pyloric  spasm,  atony  and  dilatation  of  the  stomach 
are  apt  to  supervene. 

CHRONIC  ACm  GASTRITIS 

Boas,  who  first  described  this  disease,  defines  it  as  a  gas- 
tritis with  increased  production  of  mucus  and  an  abnormally 
strong  secretion  of  hydrochloric  acid.  The  mucus  siphoned 
out  early  in  the  morning  after  the  night's  fast  may  give  a 
positive  hydrochloric  acid  reaction.  Chronic  acid  gastritis 
approaches  very  closely  to  hyperchlorhydria  so  far  as  prac- 
tical therapeutics  is  concerned.  Acid  gastritis  is  an  early 
form  of  chronic  gastritis,  and  is  found  very  frequently  in 
alcohohc  patients. 


TREATMENT   OF    HYPERACIDITY,   HYPERCHLORHYDRIA, 
SUPERACmiTY,  AND  ACID  GASTRITIS 

Hygienic  Treatment. — In  view  of  the  fact  that  hyjierchlor- 
hydria  is  often  brought  on  by  grief,  worry,  or  mental  over- 
work, it  would  appear  that  the  first  thing  to  do  is  to  regulate 


HYPERACIDITY— HYPERCIILORHYDRI  A— GASTRITIS     815 

the  daily  life  and  habits  of  the  patient.  Business  men, 
lawyers,  physicians,  clergymen,  those  whose  labor  entails 
great  responsibility,  should  be  sent  away  from  their  work 
to  an  entirely  different  environment  where  they  may  find 
at  least  temporary  relief  from  the  strain.  Women  in  social 
circles  must  be  persuaded  to  lead  a  quieter  life.  Patients 
among  the  wealthy  leisure  class  who  have  too  much  time  to 
think  over  their  bodily  functions  must  be  given  some  occu- 
pation which  will  engage  the  mind.  Persons  with  a  pre- 
disposition to  hyperchlorhydria  should,  as  a  prophylactic 
measure,  avoid  errors  in  diet,  mental  overexertion,  and  anger. 

Dietetic  Treatment. — The  dietetic  treatment  is  of  the  great- 
est importance  in  cases  of  uncomplicated  hyperchlorhydria. 
In  the  first  place,  extremes  of  temperature  should  be  avoided 
in  both  food  and  drink.  Food  should  be  eaten  slowly  and 
thoroughly  masticated,  not  only  to  facilitate  salivary  diges- 
tion, but  to  avoid  irritating  the  stomach  mechanically. 
All  substances  that  are  likely  to  irritate  the  gastric  mucosa 
must  be  eliminated  from  the  dietary.  All  kinds  of  acids, 
including  the  organic,  such  as  citric,  tartaric,  and  acetic, 
must  be  forbidden;  also  spices  of  all  kinds — pepper,  mustard, 
horseradish,  etc.  Whisky  and  wines  are  in  the  prohibited 
list. 

The  food  should  be  rich  in  protein  and  as  poor  as  possible 
in  starchy  substances.  The  total  acidity  of  the  gastric 
secretions  is  much  greater  with  a  protein  than  with  a  car- 
bohydrate diet,  but  the  amount  of  free  hydrochloric  acid 
is  much  less.  Owing  to  the  large  percentage  of  extractives 
in  meat  which  excite  the  flow  of  gastric  juice,  it  seems 
advisable  to  substitute  some  other  form  of  protein,  as  eggs, 
milk,  cheese,  or  v-egetable  protein.  However,  when  meat  is 
prescribed,  it  should  be  well  boiled  to  remove  the  extractives 
rather  than  roasted.  Raw  meat  should  be  avoided,  owing 
to  its  excessively  stimulating  effect  on  gastric  secretion. 
Oatmeal,  aleuronat  meal,  and  bread  and  cocoa  that  are  rich 
in  protein  are  all  useful  food  substances  in  the  treatment 
of  hyperchlorhydria. 

Carbohydrates  should  not  be  eliminated  entirely  from  the 


316  SECRETORY  NEUROSES 

diet  in  hyperchlorhydria,  but  should  be  restricted.  They 
may  be  taken  in  finely  divided  form;  that  is,  vegetables 
such  as  spinach  and  cauliflower  must  be  taken  as  puree. 
Salads  and  fresh  fruits  are  to  be  avoided.  When  free  hydro- 
chloric acid  appears  early,  interrupting  the  digestion  of 
carbohydrates,  amylolysis  may  be  assisted  by  the  use  of 
dextrinated  carbohydrates  (zwieback,  toast).  Sugar  has 
been  found  valuable  in  the  dietary  of  hyperacidity,  inasmuch 
as  concentrated  saccharated  solutions  diminish  not  only  the 
total  acidity,  but  likewise  the  free  hydrochloric  acid,  to  a 
marked  degree.  Sugar  may  be  given  in  a  variety  of  forms, 
such  as  sweet  dishes,  jellies,  jam  and  honey. 

Fats  fulfil  the  same  role  as  sugar.  It  has  been  demon- 
strated that  fat  not  only  hinders  gastric  secretion,  but 
diminishes  the  quantity  of  free  hydrochloric  acid.  Strauss 
prescribes  fat  after  he  has  ascertained  that  it  does  not  dis- 
turb the  motility  of  the  stomach  or  interfere  with  the  assimi- 
lation of  other  foods.  Bacon  provides  fat  in  an  agreeable 
form.     Milk,  cream,  and  butter  are  indicated. 

Oils  of  various  kinds  have  been  employed  with  good 
results  in  the  treatment  of  hyperchlorhydria.  Cowie  and 
Munson  conclude,  as  the  result  of  experimentation,  that 
olive  oil  and  cottonseed  oil,  when  given  in  connection  with 
the  usual  test  breakfast,  decrease  the  gastric  acidity  at  the 
end  of  the  hour  and  retard  the  evacuation  of  the  stomach. 
The  beginning  of  the  secretion  of  hydrochloric  acid  is  delayed 
when  oil  precedes  the  meal;  it  is  unchanged  when  the  oil 
follows  the  meal.  The  height  of  digestion  is  delayed  when 
oil  is  given  either  before  or  after  the  meal.  The  height  of 
secretion  is  lowered  when  oil  precedes  the  meal;  it  is  un- 
changed when  oil  follows  the  meal.  If  the  progress  of  diges- 
tion be  watched  by  the  removal  of  small  samples  of  stomach 
fluid  at  frequent  intervals,  it  will  be  observed,  when  oil 
precedes  the  meal  by  one-half  hour,  that  at  the  end  of  what 
is  usually  taken  as  the  digestive  period  for  a  test  breakfast 
(three-fourths  to  one  hour)  the  acidity  is  distinctly  lower, 
while  as  great  a  height  as  is  present  in  the  control  meal  is 
frequently  reached  some  minutes  later.      The  action  of  oil 


HYPERACIDITY— HYPERCIJLORII YDRI  A— GASTRITIS     317 

on  the  stomach  functions  is  only  a  temporary  one.  It  has 
no  effect  on  subsequent  meals  unaccompanied  by  oil.  The 
therapeutic  value  of  oil  is  apparent.  In  suitable  cases  it 
is  preferable  to  antacids  because  of  its  calorific  value.  In 
hyperchlorhydria  it  should  precede  the  meal.  In  hypo- 
chlorhydria  it  should  follow  the  meal.  In  stasis  and  per- 
sistent slow  evacuation  it  should  be  eschewed.  In  hyper- 
motility  it  may  be  given  before,  during,  or  after  the  meal. 
Oil  lowers  the  gastric  secretion  both  by  reflex  central  inhibi- 
tory stimulation  and  by  mechanical  action. 

Dr.  H.  W.  Wiley  says  that  one  unit  of  cottonseed  oil  will 
furnish  over  twice  as  much  heat  and  energy  as  the  same 
quantity  of  sugar  or  starch.  When  used  with  salt  on  bread 
it  makes  a  very  acceptable  substitute  for  cream  and  butter, 
and  certainly  is  free  from  the  diseases  we  contract  from  the 
animal  world.  Not  only  is  cottonseed  oil  more  easily 
digested  than  corn  oil,  peanut  butter,  or  even  olive  oil,  but 
it  does  not  ferment  in  the  stomach  and  bring  on  that  long 
train  of  evils  that  come  from  the  too  free  use  of  some  of  the 
articles  mentioned. 

Beverages  taken  at  meals  are  harmless,  inasmuch  as  they 
dilute  the  gastric  juice.  Alkaline  mineral  waters,  Vichy, 
and  California  seltzer  waters  containing  no  carbon  dioxide, 
may  be  prescribed  in  large  quantities.  Beer  and  coffee 
should  be  avoided.  Cocoa  and  weak  tea  well  diluted  with 
milk  are  permissible.  Pure  milk,  however,  is  the  ideal 
beverage  in  these  cases. 

Strauss  recommends  the  following  menu  as  a  model  for 
a  mid-day  meal:  A  few  tablespoonfuls  of  olive  oil,  if  not 
objectionable  to  the  patient  (if  olive  oil  cannot  be  borne, 
give  a  few  small  butter  balls);  cold  toast  well  buttered;  a 
sardine  in  oil,  or  a  small  amount  of  fresh  fat  cheese.  Yolks 
of  eggs  may  be  taken  before  the  meal.  The  meat  course 
should  consist  of  boiled  meat,  fowl,  or  fish,  served  with 
cream  or  butter  sauces.  Vegetables,  in  the  form  of  puree 
of  spinach,  beans,  or  carrots,  may  be  permitted.  For  dessert, 
sweet  boiled  fruit,  sweet  dishes,  or  pudding  with  fruit  sauce. 


318  SECRETORY  NEUROSES 

Outline  of  Diet  in  Hyperchlorhydria  (Einhorn) 

Calories. 

7.30  a.m.      Two  eggs,  50  Gm 160 

\Mieaten  bread,  50  Gm 128 

Butter,  20  Gm 163 

Milk,  250  Gm 169 

10.30  a.m.      Matzoon  or  milk,  200  Gm 135 

Crackers  or  bread,  30  Gm 77 

Butter,  10  Gm 81 

1.00  p.m.       Broiled  meat,  100  Gm. 210 

jMashed  potatoes,  50  Gm 63 

Bread,  30  Gm 77 

Butter,  10  Gm 81 

Weak  tea  or  Vichy  water,  200  Gm. 

3.30  p.m.      Same  as  at  10.30  a.m 293 

6.30  p.m.      Soup  (with  barley  or  vermicelli),  200  Gm 100 

Bread  and  butter  (bread,  30  Gm.;  butter,  10  Gm.)      .  158 

Meat  broiled  or  cooked,  100  Gm 210 

Potatoes,  baked,  50  Gm 60 

Green  vegetables  (spinach,  green  peas),  50  Gm.     .      .  80 

Coffee  (half  milk),  100  Gm 34 

10.00p.m.      Oysters  and  crackers,  or  cold  meat  sandwich     .      .      .  260 

2539 

Diet  in  Hyperchlorhydria  (Habershon) 

1.  Avoidance  of  foods  that  stimulate  secretion,  i.  e.,  all  condiments,  highly 

spiced,  flavored  or  seasoned,  cured,  tinned,  or  salted  foods,  and  beef 
foods  and  extracts,  on  account  of  their  properties  which  excite  secretion. 

2.  The  free  administration  of  alkalies  or  vegetables  that  contain  alkalies,  and 

of  all  oily  or  fatty  foods.  All  green  vegetables  may  be  taken  if  they 
suit,  such  as  spinach,  cabbage,  bunch  greens,  turnip-tops,  broccoli, 
Scotch  kale,  and  salads  (such  as  watercress,  endive,  the  leaf  of  lettuce, 
taraxacum),  etc.  Fat  meat  and  bacon  or  ham,  butter,  cream,  and 
milk  may  be  taken. 

3.  All  freshly  cooked  meats  and  fish,  with  eggs,  and  vegetable  proteins, 

beans,  peas,  lentils,  etc.,  are  freely  digested.  Scraped  meat,  raw  or 
very  highly  cooked,  is  often  well  digested. 

4.  Excess  of  carbohydrate  food,  i.  e.,  articles  of  food  containing  starch  and 

sugar,  should  be  avoided.  These  are:  starch-containing  vegetables, 
cereals,  and  fruits;  potatoes,  and  most  of  the  roots  and  tubers,  such  as 
carrots,  turnips,  parsnips,  artichokes,  beetroot,  radishes,  etc.;  white 
or  whole-meal  bread;  rice,  sago,  and  other  puddings  derived  from 
cereals;  sugar  and  syrupy  fruits. 

5.  All  acid  vegetables  and  fruits  are  also  to  be  avoided,  such  as  rhubarb, 

tomatoes,  cucumbers,  lemons,  and  oranges;  the  spring  and  summer 
fruits — currants,  raspberries,  gooseberries,  cranberries,  mulberries, 
apples,  pears,  plums,  cherries,  strawberries,  grapes,  peaches,  nectarines; 
likewi.se  all  acid  drinks. 


HYPERACIDITY— HYPERCHLORHYDRI  A— GASTRITIS     319 

6.  Bananas  may  be  taken,  also  prunes,  nuts,  cheese,  etc. 

7.  All  malt  liquors,  and  claret,  sherry,  hock,  moselle,  and  sweet  wines,  such 

as  liqueurs,  port,  and  champagne,  should  be  avoided.  The  only  stimu- 
lants permissible,  if  these  be  needed,  are  whisky  and  brandy  in  small 
quantities,  well  diluted,  and  in  medicinal  doses;  but  the  patient  is  far 
better  without  stimulants. 

Large  quantities  of  fat  are  particularly  indicated  in  cases 
of  hyperacidity  accompanied  by  constipation.  On  the  other 
hand,  a  purely  vegetarian,  lactovegetable  or  meat-poor 
regimen  is  recommended  in  pronounced  nervous  forms  of 
hyperacidity;  the  vegetables  should  be  thoroughly  cooked 
and  finely  divided. 

Regarding  the  frequency  of  meals,  it  is  advisable  to  eat 
five  or  six  times  a  day,  three  heavy  and  two  or  three  light 
meals. 

Laufer  attaches  great  importance  to  the  salt-free  diet  in 
hyperchlorhydria  patients,  and  Hayem  maintains  that  an 
abnormally  high  percentage  of  hydrochloric  acid  can  be 
reduced  by  an  almost  salt-free  diet.  Vincent  attempts  to 
show  a  more  or  less  strict  paralleHsm  between  the  percentage 
of  hydrochloric  acid  in  the  gastric  juice  and  the  quantity 
of  sodium  chloride  ingested.  He  made  observations  on  a 
young  subject,  aged  twenty-two  years,  examining  the 
stomach  contents  one  hour  after  the  ingestion  of  the  test 
meal,  which  was  always  given  in  the  morning.  The  first 
test  was  to  find  the  effect  of  a  thorough  chlorination  by 
adding  12  grammes  of  sodium  chloride  per  day  to  an  ordinary 
diet;  the  gastric  juice  was  examined  two  and  four  days 
later.  The  second  test  was  a  complete  prohibition  of  sodium 
chloride  for  ten  days.  In  the  first  instance  a  violent  hyper- 
chlorhydria developed,  attended  by  the  usual  pathologic 
symptoms.  But  when  the  salt-free  diet  was  established  the 
symptoms  disappeared  and  the  subject  gained  six  pounds  in 
weight. 

Enriquez  and  Ambard  report  the  results  of  recent  research 
which  confirm  their  previous  assertions  in  regard  to  the 
beneficial  effect  of  withdrawing  salt  when  the  secretion  of 
gastric  juice  is  excessive  and  the  stomach  responds  with  pain. 
In  such  cases  a  salt-free  diet  has  a  prompt  and  marked  influ- 


320  SECRETORY  NEUROSES 

ence  on  the  excessive  secretion;  the  influence  on  the  pains 
is  not  felt  so  soon.  Once  estabUshed,  the  effect  is  lasting, 
the  pain  subsiding  permanently  and  completely  in  two  or 
three  weeks,  or  at  most  in  five.  As  soon  as  the  pain  has 
been  banished  by  a  strictly  salt-free  diet,  the  patient  is 
allowed  to  have  his  own  salt-cellar  to  use  as  desired,  the 
food  being  still  prepared  without  salt.  This  gives  the  patient 
a  feeling  of  freedom  which  renders  the  restriction  less  irk- 
some, and,  as  the  capacity  of  the  salt-cellar  is  known,  the 
exact  amount  he  is  taking  can  be  estimated.  The  salt-free 
diet,  according  to  these  writers,  should  be  instituted  in 
every  case  of  hyperchlorhydria  rebellious  to  other  measures. 

M.  Bonniger,  Pawlow  says,  observed  the  behavior  of 
the  gastric  juice  secreted  by  a  dog  with  a  gastric  fistula. 
The  result  of  the  administration  of  salt  was  a  very  marked 
diminution  of  the  gastric  secretion,  with  a  corresponding 
diminution  of  the  hydrochloric  acid  secreted.  Similar  results 
were  obtained  with  a  healthy  ^man — marked  subacidity 
without  increase  in  the  total  amount  of  gastric  juice.  A 
priori,  then,  common  salt  would  seem  to  be  indicated  in  the 
treatment  of  hyperacidity.  "WTiether  the  ill  effects  of  large 
doses  of  salt — interference  with  gastric  motility  and  with 
protein  digestion — suffice  to  counterbalance  its  good  effects 
in  this  disease,  can  only  be  settled  by  chnical  observation. 
Notwithstanding  the  observations  of  Bonniger,  chnical  ex- 
perience tends  to  confirm  the  views  of  Laufer. 

Medicinal  Treatment.  —  Astringents.  —  The  astringents  are 
among  the  most  valuable  drugs  we  have  in  the  treatment  of 
hyperchlorhydria.  Their  action  is  confined  to  the  gastric 
mucosa.  They  diminish  the  intensity  of  local  inflammation. 
Astringents  are,  therefore,  indicated  in  the  treatment  of 
chronic  gastritis  when  the  inflammatory  process  is  superfi- 
cial. Owing  to  their  inhibitory  eff'ect  upon  secretion,  they 
are  contraindicated  in  conditions  where  the  acid  secretion 
is  normal,  subnormal,  or  absent. 

Among  the  more  valuable  astringents  are  the  salts  of 
bismuth  and  silver.  The  physical  effect  of  bismuth  subni- 
trate  is  the  formation  of  a  protective  layer  over  the  gastric 


//  YFERACIDIT  Y—H  YPERCIILORH  YDRI  A— GASTRITIS      321 

mucosa,  which  is  particularly  desirable  where  abrasions 
exist.  Rodari  found,  by  animal  experimentation,  that  bis- 
muth inhibits  gastric  secretion;  the  subnitrate  materially 
diminishes  the  quantity  of  free  hydrochloric  acid.  He  found 
the  inhibitory  action  of  the  drug  to  be  more  marked  when 
the  gastric  mucosa  was  inflamed.  The  action  of  hydrochloric 
acid  upon  bismuth  subnitrate  in  the  stomach  is  represented 
by  the  following  equation : 

NO3  Cl 

/  / 

Bi         +  HCl  =  HNO3  +  Bi 

According  to  Rodari,  bismuth  subcarbonate  has  no  appre- 
ciable action  upon  the  gastric  secretion.  He  attributes  the 
inhibitory  effect  of  bismuth  subnitrate  to  the  nitric  acid 
formed  by  the  action  of  hydrochloric  acid  upon  it.  Bis- 
muth subnitrate  is  indicated  in  the  treatment  of  hyper- 
acidity, hypersecretion,  and  acid  gastritis.  It  is  contra- 
indicated  in  chronic  gastritis  of  all  other  forms. 

Rodari's  animal  experiments  showed  that  the  silver  com- 
pounds (silver  nitrate,  protargol,  albargin)  diminish  the 
quantity  of  gastric  juice  in  inflammatory  conditions  of  the 
gastric  mucous  membrane,  but  increase  the  amount  of 
hydrochloric  acid  slightly.  In  the  absence  of  inflammation, 
however,  the  silver  salts  were  found  to  increase  gastric 
secretion.  Nitrate  of  silver,  accordingly,  would  be  indicated 
in  cases  of  gastritis  with  either  normal  or  subnormal  acidity, 
rather  than  in  hyperacidity,  hypersecretion,  or  acid  gastritis. 
I  have  obtained  good  results,  however,  from  the  use  of  silver 
nitrate  in  hyperacid  conditions,  whether  accompanied  by 
catarrh  or  not,  and  also  in  hypersecretion.  I  would  not 
eliminate  the  silver  salts  from  the  therapeutic  agents  appli- 
cable to  these  conditions. 

Regarding  the  action  of  silver  nitrate  in  mitigating  the 
symptoms  of  hyperacidity,  Kaufmann^  writes:  ^'No  treat- 
ment removes  more  quickly  all  the  so-called  hyperacidity 

1  American  Journal  of  the  Medical  Sciences,  February,  1908. 
21 


322  SECRETORY  NEUROSES 

symptoms  than  the  appHcation,  by  lavage,  of  solutions  of 
silver  nitrate.  I  can  state  this  positively  on  the  strength 
of  an  experience  gained  by  the  treatment  of  hundreds  of 
cases.  When  after  such  treatment  and  after  the  patients 
had  been  perfectly  free  from  all  subjective  symptoms  the 
stomach  contents  were  again  examined,  I  have  often  been 
greatly  surprised  to  find,  instead  of  the  expected  lowering 
of  the  acidity,  that  the  high  figures  of  hyperacidity  had 
remained  unchanged.  It  has  already  been  pointed  out  by 
Baibakoff  that  the  application  of  silver  nitrate  does  not 
necessarily  reduce  the  secretion  of  the  gastric  juice.  Although 
I  have  observed  in  certain  cases  a  decided  lowering  of  the 
acidity  after  the  treatment  with  silver  nitrate,  such  lowering 
was  not  the  rule.  I  have  seen  more  cases  in  which  the  acidity 
remained  high;  in  fact,  in  some  I  found  even  a  higher  degree 
of  acidity  after  the  treatment  than  they  had  before  the 
treatment.  And  yet  these  patients  had  been  freed  of  their 
annoying  symptoms  by  the  use  of  silver  nitrate,  and  many 
of  them  had  been  promptly  relieved  from  severe  pains." 

Bismuth  subnitrate  is  administered  in  powder  form,  1 
to  4  Gm.  (15  to  60  grains)  in  warm  water,  fifteen  minutes 
before  each  meal.  Nitrate  of  silver  is  given  in  solution 
(1  to  750  to  1  to  1000),  one  tablespoonful  and  a  half  in  half 
a  glass  of  distilled  water. 

Atropine. — The  effect  of  astringents  is  directly  upon  the 
gastric  glands.  Atropine  acts  through  the  central  nervous 
system,  inhibiting  gastric  secretion,  and  diminishing  the 
quantity  of  hydrochloric  acid  in  the  gastric  juice  without 
interfering  with  the  secretion  of  pepsin.  Atropine,  further- 
more, acts  as  an  antispasmodic  and  analgesic;  it  diminishes 
the  sensibility  of  the  sensory  nerves.  Atropine  sulphate  in 
doses  of  ^  to  1  milligramme  (jhj  to  -/,7  grain),  given  in 
the  form  of  tablets,  is  a  useful  agent  for  promptly  relieving 
the  painful  attacks  of  pylorospasm.  When  atropine  is  to 
be  administered  over  a  long  period  of  time  it  is  best  given 
as  extract  of  belladonna,  0.02  to  0.03  Gm.  (^  to  §  grain) 
three  times  a  day,  before  meals;  or  it  may  be  advantageously 
given  with  astringents  and  alkalies.     Atropine  is  a  poison, 


HYPERACIDITY— II YPERCHLORHYDRI  A— GASTRITIS      323 

and  when  it  is  necessary  to  secure  its  therapeutic  effect  for  a 
considerable  length  of  time  some  relatively  harmless  sub- 
stitute should  be  considered.  Among  the  less  poisonous 
substitutes  we  have  eumydrin,  which  is  supposed  to  be 
fifty  times  less  toxic  than  atropine  (see  page  196). 

Guis.  Massini  writes  concerning  eumydrin  as  follows: 
"Seeing  that  atropine  readily  gives  rise  to  general  disturb- 
ances and  intoxications,  eumydrin  proves  itself,  in  many 
cases,  an  advantageous  substitute.  In  doses  of  from  1  to  3 
milligrammes  (gV  to  -^V  grain)  it  can  be  given  for  some  time 
without  producing  any  severe  general  disturbances.  Most 
satisfactory  this  agent  proves  to  be  in  gastric  neuroses  with 
hyperchlorhydria  and  increasing  gastric  pains."  This  drug 
has  been  recommended  by  Zweig  and  Wegele.  The  former 
prescribes  it  as  follows : 

Gm.  or  Cc. 

I^ — Eumydrin 0.04  gr.  | 

Sacchari  6.0  5iss 

Misce  et  ft.  pulv.  no.  xx. 

Si^. — One  three  times  a  day,  before  meals. 

Other  drugs  that  act  similarly  to  atropine  in  retarding 
secretion  are  euphthalmin  and  scopolamine  hydrobromide; 
the  latter,  prescribed  in  doses  of  0.0003  Gm.  {-j^-(j  grain),  has 
been  found  useful  in  the  treatment  of  hypersecretion. 
Neither  of  these  drugs  has  been  used  very  extensively. 

Hydrogen  Peroxide. — Petri '^  has  lately  shown  that  hydrogen 
peroxide,  taken  internally,  exerts  a  marked  influence  on  the 
hydrochloric  acid  output.  He  found  by  studies  on  himself 
that  even  a  1-per-cent.  solution  could  be  taken  without  any 
ill  effects,  apart  from  a  burning  taste  in  the  mouth  accom- 
panied by  the  formation  of  oxygen  bubbles  and  a  feeling 
of  constriction  in  the  esophagus.  No  gastric  symptoms  were 
observed.  Solutions  0.25  to  0.75  per  cent,  in  strength  were 
easily  taken,  and  patients  to  whom  these  were  given  com- 
plained of  no  unpleasant  complications.  Goodman,  from 
work  done  in  Musser's  private  laboratory,  states  that  good 
results  have  been  obtained  with  a  teaspoonful  of  hydrogen 
peroxide  in  a  glass  of  water  after  meals,  but  two  teaspoon- 

1  Archiv  fiir  Verdauungs  Krankheiten,  1908.  xiv,  p.  479. 


324  SECRETORY  NEUROSES 

fuls  may  be  taken  with  no  unpleasant  consequences.  He 
says:  ^'I  regard  hydrogen  peroxide  as  an  additional  remedy 
in  an  already  long  list  of  measures  advocated  in  the  treat- 
ment of  hyperchlorhydria.  Its  value  is,  however,  not  so 
great  that  all  other  means  of  treatment  may  be  relegated 
to  oblivion,  but  in  conjunction  with  these  it  will  no  doubt 
be  found  of  benefit." 

Magnesium  peroxide  has  been  introduced  to  the  profession 
under  the  trade  name  of  magnesium  perhydrol.  It  is  pre- 
pared by  treating  magnesium  oxide  with  hydrogen  peroxide. 
It  is  a  white,  tasteless,  odorless  powder,  insoluble  in  water, 
but  soluble  in  dilute  acids.  It  is  prepared  in  two  strengths, 
containing  respectively  ISMgOj  +  85MgO  and  25Mg02  + 
75MgO.  When  kept  for  a  long  time,  it  is  reconverted  into 
magnesium  oxide.  This  preparation  has  been  found  useful 
in  diminishing  hyperacidity.  The  dose  is  1  Gm.  (15  grains) 
three  times  a  day. 

Alkaloids. — Of  the  alkaloids,  codeine  is  the  only  one 
besides  atropine  that  does  not  occasion  untoward  after- 
effects. Morphine,  after  temporarily  inhibiting  secretion, 
is  apt  to  cause  a  very  copious  flow  of  hyperacid  gastric 
juice.  Dionin  and  pilocarpine  immediately  increase  the 
secretion.  Codeine  may  be  given  in  doses  of  0.01  to  0.03 
Gm.  (l  to  ^  grain)  with  extract  of  belladonna  or  with 
alkalies  and  astringents. 

Analgesics. — The  following  analgesic  agents  have  been 
found  efficacious:  Cannabis  indica  extract,  0.01  to  0.05  Gm. 
(^  to  1  grain)  three  times  daily;  chloral  hydrate;  and  chloro- 
form water  (1  to  200).  According  to  Wegele,  chloroform 
acts  better  when  taken  in  drop  doses  on  cracked  ice.  Cocaine 
is  efficacious  in  painful  vomiting.  Menthol  and  validol  act 
like  cocaine.  The  bromides  are  occasionally  very  useful  in 
the  nervous  form  of  hyperacidit}^  Bromide  of  strontium, 
2  to  4  Gm.  (30  to  60  grains)  daily,  is  recommended,  espe- 
cially by  French  authors. 

t!ni.  or  Cc. 

I^ — Extract!  cannabis  indicso 0.3         gr.  v 

Extract!  gentianic q.  s. 

Misco  et  ft.  pil.  no.  xx. 

Sig. — One  three  times  daily. 


HYPERACIDITY— H  YPERCHLORHYDRI  A— GASTRITIS      325 

Gill,  or  Cc. 

I^— Chornli  hydrati 2.0         gr.  xxx 

Aquir  destillat£B 10.0        oiiss 

Misce. 

Sig. — Ten  to  twenty  drops  three  times  a  day. 

Gm.  or  Cc, 

I^— Cocaina)  hydrochloridi, 

Codeinse  phosphatis ajl         0.5         gr.  viiss 

Syrupi  aurantii q.  s.  ad     150.0        §v 

Misce. 

Sig. — One  tcaspoonful  every  hour  until  reUeved. 

Alkalies. — Alkalies  are  the  remedies  that  are  employed 
most  frequently  in  the  treatment  of  hyperchlorhydria. 
Experimental  research  concerning  the  effect  of  alkahes  in 
the  stomach  has  estabhshed  the  fact  that,  reaching  the 
stomach  in  sufficient  quantities,  they  are  capable  of  neutral- 
izing the  hydrochloric  acid  secreted.  Consequently  they 
should  be  introduced  into  the  stomach  when  hydrochloric 
acid  is  secreted  in  excess.  The  following  alkalies  serve  these 
purposes : 

Salts  of  Alkali7ie  Earths. — The  principal  members  of  this 
class  are  magnesium  oxide  and  ammonio-magnesium  phos- 
phate. Magnesium  oxide  combines  with  hydrochloric  acid 
according  to  the  following  formula : 

MgO  +  2HC1  =  MgCls  +  H2  O 

The  ammonio-magnesium  phosphate  combines  thus : 

Mg(NH4)P04  +  3HC1  =  MgCl2  +  NH4CI  +  H3PO4 

The  carbonated  alkahes:  Sodium  bicarbonate  is  particu- 
larly useful.  It  combines  with  hydrochloric  acid  according 
to  the  following  formula : 

NaHCOs  +  HCl  =  NaCl  +  H2O  +  CO2 

It  has  been  shown  that  bicarbonate  of  soda  not  only 
neutralizes  the  acid,  but  also  diminishes  the  secretion. 

Carbonate  of  soda  is  used  but  rarely,  owing  to  its  caustic 
effect  on  the  mucous  membrane. 

Of  the  drugs  mentioned,  magnesium  oxide  is  capable  of 


326  SECRETORY  NEUROSES 

neutralizing  the  greatest  amount  of  acid.  The  next  in 
order  is  animonio-magnesium  phosphate.  To  neutrahze 
equal  quantities  of  hydrochloric  acid,  four  times  as  much 
bicarbonate  of  soda  as  of  magnesium  oxide  is  required,  and 
twice  as  much  as  of  the  ammonio-magnesium  phosphate. 

The  quantities  of  these  drugs  which  it  is  necessary  to 
administer  vary  according  to  the  degree  of  hyperacidity 
or  hypersecretion.  Boas  calculates,  for  a  hyperacidity  with 
more  than  25  per  cent,  hydrochloric  acid,  8  to  10  grammes 
(oij-iiss)  of  bicarbonate  of  soda,  2  to  3  grammes  (30  to 
45  grains)  of  magnesium  oxide,  and  4  to  6  grammes  (5j- 
iss)  of  ammonio-magnesium  phosphate.  These  quantities 
refer  to  full  meals,  and  must  be  reduced-  one-half  for  small 
meals.  In  the  presence  of  an  acidity  exceeding  3  per  cent, 
of  hydrochloric  acid.  Boas  gives  the  dose  of  bicarbonate 
of  soda  as  12  grammes;  magnesium  oxide,  5  grammes; 
ammonio-magnesium  phosphate,  5  grammes.  These  figures 
are  to  be  considered  only  as  a  general  guide  for  the  dosage 
required.  Boas,  however,  maintains  that  they  are  by  no 
means  too  high — rather  the  contrary. 

In  some  forms  of  disease  with  symptoms  of  hyperacidity 
it  is  advisable  to  avoid  the  carbon  dioxide  alkalies,  on 
account  of  the  gastric  distention  that  is  likely  to  follow 
from  the  formation  of  gas. 

An  alkaline  remedy  frequently  used  in  gastric  disorders 
is  Carlsbad  water  and  its  salts.  The  chapter  on  INIineral 
Waters  discusses  Carlsbad  waters.  The  Carlsbad  salts  are 
prepared  in  various  forms:  Natural  crystalline  Carlsbad 
sprudel  salt  consists  (after  removal  of  the  water  of  crystal- 
hzation)  of  sulphate  of  soda,  99.33;  carbonate  of  soda,  0.45; 
and  common  salt,  0.76. 

Natural  pulverized  Carlsbad  sprudel  salt  has  the  follow- 
ing composition: 

Per  cent. 

Sulphate  of  soda 41.62 

Sulphate  of  potash 3.31 

Carbonate  of  .soda 36.11 

Clilorido  of  aodiuiii IS.  19 

Carbonate  of  lithium       ...            0.02 

Borate  of  sodium 0.03 

Water 0.44 


//  YPERACIDITY—H  YPERCHLORH  YDRIA— GASTRITIS     327 

Ai'tificial  Carlsbad  salt  consists  of: 

Per  cent. 

Sulphate  of  soila 44 . 0 

Sulphate  of  potash 2.0 

Chloride  of  soda 18.0 

Bicarbonate  of  soda 36 . 0 

These  salts  are  similar  in  their  effects.  The  artificial  salt 
is  cheaper,  but  the  natural  salt  has  a  more  agreeable  taste. 

The  Carlsbad  salts  may  be  administered  in  varying  doses. 
The  smallest  dose  is  5  grammes,  equal  to  one  teaspoonful; 
the  average  dose,  10  grammes  (2  teaspoonfuls) ;  and  the  maxi- 
mum dose,  15  grammes  (3  teaspoonfuls) .  Doses  of  5  grammes 
may  be  taken  at  one  draught,  dissolved  in  a  quarter  of  a 
liter  (one  glass)  of  water. 

To  avoid  irritation  of  the  stomach,  not  more  than  15 
grammes  should  be  taken  at  one  draught.  Carlsbad  salt  is 
usually  taken  early  in  the  morning,  on  an  empty  stomach, 
each  dose  being  5  grammes,  and  the  doses  being  separated 
by  a  considerable  interval  of  time.  When  two  dessert- 
spoonfuls are  to  be  taken,  the  interval  between  them  should 
be  thirty  to  forty-five  minutes;  when  three  dessertspoonfuls 
are  taken,  the  interval  between  the  first  and  second  spoonful 
should  be  thirty  minutes,  that  between  the  second  and  third 
spoonful  forty-five  minutes.  One  whole  hour  should  elapse 
after  the  last  dose  before  breakfast  is  taken.  Carlsbad  salt 
is  taken  in  various  vehicles,  such  as  ordinary  water,  Carls- 
bad mineral  water,  or  an  aerated  carbonated  water  (Vichy, 
Apolhnaris).  The  temperature  of  the  Carlsbad  salt  solution 
should  be  about  30°  C.  A  lukewarm  solution  has  a  more 
purgative  effect  than  one  of  high  temperature.  The  Carls- 
bad salt  fulfils  indications  similar  to  those  for  the  other 
alkalies  mentioned. 

A  salt  mixture  similar  to  the  artificial  Carlsbad  salt  is 
Wolff's  mixture,  consisting  of: 

Grammes. 

Sulphate  of  sodium 30.0 

Sulphate  of  potassium 5.0 

Chloride  of  sodium 30.0 

Carbonate  of  sodium 25.0 

Bicarbonate  of  sodium 10.0 


328  SECRETORY  NEUROSES 

This  is  to  be  taken  three  times  a  day,  early  in  the  morning, 
two  hours  before  dinner,  and  two  hours  before  supper,  in 
half-teaspoonful  doses  dissolved  in  half  a  tumblerful  of 
lukewarm  water.  This  powder  is  specially  recommended  in 
cases  in  which  gastric  juice  is  secreted  in  the  morning  before 
food  has  been  ingested. 

In  the  absence  of  saliva,  Sticker  and  Biernacki  recommend 
the  administration  of  jaborandi  or  pilocarpine,  since  these 
drugs  are  known  to  be  sialagogues.  The  absence  of  salivary 
secretion  retards  amylolysis  greatly,  and  proteolysis  as  well. 
In  cases  of  such  pronounced  hyperacidity  that  salivary 
digestion  is  inhibited,  Boas  recommends  administering 
ptyalin  or  malt  diastase  combined  with  alkalies.  I  think, 
however,  that  in  such  conditions  the  object  could  be  better 
accomplished  by  more  prolonged  mastication  and  insaliva- 
tion  of  the  food. 

In  cases  of  hyperacidity  the  proper  times  for  the  adminis- 
tration of  alkalies  are:  directly  after  eating,  and  at  the 
height  of  digestion,  when  the  secretion  of  acid  is  freest. 
Patients  are  frequently  able  to  tell  this  particular  moment 
with  considerable  exactness,  as  it  coincides  with  the  onset 
of  their  painful  symptoms. 

Course  of  Medication. — The  course  of  medication  in  hyper- 
chlorhydria  is  as  follows :  In  hght  cases  the  attempt  is  made 
with  alkalies  alone.  When  the  cases  are  more  obstinate  and 
cause  much  discomfort,  astringents  may  be  given  in  addition 
to  the  alkalies.  Severe  cases,  especially  those  with  severe 
pains,  a  high  degree  of  acidity,  and  pylorospasm,  require  the 
administration  of  the  alkaloids,  combined  with  alkalies  and 
astringents.     Attendant  constipation  has  to  be  treated. 

Lavage  of  the  Stomach. — In  cases  of  hyperchlorhydria  com- 
plicated with  atony  or  disturbances  in  motility,  lavage  of 
the  stomach  is  useful.  Lavage  may  be  performed  late  at 
night  after  an  early  supper,  or  early  in  the  morning.  It 
should  be  followed  by  a  solution  of  Carlsbad  salt  or  nitrate 
of  silver  (1  to  1000),  to  be  washed  out  witli  i)ui'(>  water. 

The  mineral  waters  have  jii-ovod  to  be  \ahial)le  thera- 
peutic agents  in  the  treatment  of  hyperchloi'hydi-ia.  Cai'lsbad 


HYPERACIDITY— HYPERCHLORHYDRI  A— GASTRITIS     329 

occupies  the  first  place.  The  alkahne  acidulous  waters  are 
indicated  in  purely  nervous  hyperacidity.  The  mineral  water 
cures  are  better  taken  at  the  respective  resorts,  but  may  be 
employed  with  advantage  at  home. 

Physiotherapeutic  measures  are  indicated  as  palliatives 
in  severe  cases  only,  where  something  must  be  done  at  once. 
Hot  compresses  over  the  region  of  the  stomach  mitigate  the 
severity  of  pain.  The  Winternitz  stomach  application  has  a 
quieting  and  antispasmodic  action. 

The  treatment  of  acid  gastritis  is  the  same  as  that  of 
hyperacidity  in  respect  to  diet,  medication,  and  mineral 
water  treatment. 

In  chlorotic  patients  Einhorn  advises  the  administration 
of  an  organic  iron  preparation,  recommending  such  prepara- 
tions as  Pizzala's  or  Dietrich's  elixir  of  peptonate  of  iron,  or 
Boehringer's  ferratin.  I  prefer  the  hypodermic  administra- 
tion of  the  citrate  of  iron,  as  described  on  page  240. 

Milk  of  magnesia  is  a  suspension  of  magnesium  hydroxide 
in  water.  A  dose  of  one-half  to  two  tablespoonfuls  will 
neutralize  the  acid  in  hyperacidity,  and  will  act  favorably 
when  this  condition  is  complicated  with  constipation. 

In  the  treatment  of  hyperacidity  the  alkaline  powders 
are  effective.  The  following  formulas  for  combinations  of 
alkaline  substances  will  be  found  serviceable  in  various 
conditions : 

Gm.  or  Cc. 

I^ — Sodii  bicarbonatis 4.0  3j 

Magnesii  oxidi 4.0  3i 

Calcii  carbonatis 6.0  3iss 

Misce  et  ft.  pulv. 

Sig. — Take  one  teaspoonful  immediately  after  each  meal,  with  a  little 
water.     The  dose  may  be  increased  or  diminished  as  required. 


Gm.  or  Cc. 

10.0 

oiiss 

40.0 

ox 

I^ — Magnesii  oxidi 

Sodii  bicarbonatis 

Misce  et  ft.  pulv. 

Sig. — One-half  to  one  teaspoonful  three  times  a  day.  one  or  two  hours 
after  meals,  in  half  a  glass  of  water. 


330  SECRETORY  NEUROSES 

Gm.  or  Cc. 

I^ — Magnesii  oxidi 1.6  gr.  xxv 

Calcii  carbonatis 0.8  gr.  xiiss 

Bismuthi  subnitratis O.S  gr.  xiiss 

Sodii  bicarbonatis 1.0  gr.  xv 

Acetanilidi 0.12  gr.  ij 

Misce  et  ft.  pulv. 

Sig. — Take  in  a  little  water  at  the  time  of  the  attack  of  pain,  and  repeat 
if  necessary. 

Gm.  or  Cc. 

I^ — Bismuthi  subnitratis 20 . 0  5  v 

Magnesii  oxidi 10.0  Siiss 

Sodii  bicarbonatis 10.0  5iiss 

Misce  et  ft.  chart,  no.  xx. 

Sig. — One  three  times  daily,  before  meals. 

Gm.  or  Cc. 

I^ — Magnesii  oxidi, 

Pulveris  radicis  rhei aa       20 . 0  5  v 

Sodii  bicarbonatis 40 . 0  5  x 

Misce. 

Sig. — One-half  to  one  teaspoonful  in  water  one  to  two  hours  after  meals. 

Hyperacidity  with  diarrhea : 

Gm.  or  Cc. 

I^ — CretEe  prseparatce 10.0  oiiss 

Bismuthi  subgallatis 10.0  5iiss 

Sodii  bicarbonatis 10.0  oiiss 

Misce  et  ft.  chart,  no.  xx. 

Sig. — One  six  times  daily. 

Hyperacidity  with  pain : 

I^ — Codeinte  phosphatis 

Cretae  pra^parata; 

Bismuthi  subnitratis 

Magnesii  oxidi 

Sodii  bicarbonatis 

Misce  et  ft.  chart,  no.  xv. 

Sig. — One  powder  to  be  taken  one  liour  after  meals. 


Gm.  or  Cc. 

0.25 

gr.  iv 

4.0 

oi 

10.0 

oiiss 

4.0 

5j 

10.0 

oiiss 

Gm.  or  Cc. 

1^ — Cocaina>  hydrochloridi 

0.10 

gr.  1S3 

Heroinaj  hydrochloridi 

0.02 

fjr.  i 

Atropinte  sulphatis 

0.01 

gr.  i 

Extract!  ergotaj 

1.0 

gr.  XV 

Aqua)  destillata' 

10.0 

oiiss 

Misce. 

Sig. — Five  to  twenty  drops  every  hour  uiiti 

relieved. 

H  YPERACIDITY—H  YPERCIILORH  YDRIA— GASTRITIS     331 

If  between  meals  there  is  burning  or  pain  in  the  stomach 
due  to  hyperchlorhydria,  Stockton  gives  the  following  gas- 
tric sedative: 

Gm.  or  Cc. 

I^ — Ccrii  oxalatis 10.0  5  iiss 

Bismuthi  subcarbonatis 20 . 0  5  v 

IMagnesii  oxidi 40 . 0  5  x 

Misce  et  ft.  pulv. 

Sig. — A  teaspoonful  stirred  in  water;  repeat  in  an  hour  if  needed. 


CHAPTER    Xy 

SECRETORY    NEUROSES    (Coxtixued):   HYPERSECRETION— GAS- 
TRORRHEA— GASTROSUCCORRHEA— GASTROCHYLORRHEA 

The  term  ''gastrosuccorrhea"  was  introduced  into  medical 
literature  as  representing  a  clinical  entity  in  1882,  by 
Reichmann.  In  gastrosuccorrhea,  or  hypersecretion,  the 
glands  of  the  stomach  secrete  gastric  juice  constantly;  con- 
siderable amounts  may  be  found  in  the  fasting  stomach, 
before  the  first  meal  of  the  day.  Opinions  vary  as  to  the 
quantity  of  gastric  juice  that  indicates  hypersecretion.  The 
percentage  of  hydrochloric  acid  may  or  may  not  be  above 
the  normal. 


INTERMITTENT  OR  PERIODIC  HYPERSECRETION;  ACUTE 
OR  INTERMITTENT  GASTRORRHEA 

Etiology. — In  ascertaining  the  cause  of  hj^persecretion  we 
must  look  to  the  nervous  system.  Among  the  etiologic  factors 
we  have  neurasthenia,  hysteria,  anger,  worry,  and  mental 
overexertion.  Young  adults  are  particularly  prone  to  attacks. 
It  is  highly  probable  that  chronic  hyperacidity  may  induce 
acute  hypersecretion,  especially  when  the  gastric  mucous 
membrane  is  being  irritated.  A  perfectly  healthy  mucous 
membrane  with  habitually  normal  secretion  may,  however, 
produce  a  flow  of  hyperacid  gastric  juice  on  the  ingestion  of 
certain  articles  of  diet;  very  cold  beverages  may  occasion 
hypersecretion.  Acute  hypersecretion  occurs  not  infre- 
quently after  the  healing  of  gastric  ulcer;  the  exciting  cause 
is  presumed  to  be  the  cicatrix  of  the  ulcer. 

Symptoms. — Hypersecretion  appearing  at  regular  intervals 
is  characterized  by  violent  pain  and  copious  vomiting  of 


INTERMITTENT  OR  PERIODIC  IIYI'ERSECRETION     333 

acid  materials.  As  a  rule,  the  seizures  are  sudden  and  not 
anticipated  by  the  patient;  they  occur  mostly  during  the 
night  or  in  the  early  morning  hours.  After  the  expulsion  of 
food  remnants,  the  vomited  matter  consists  of  varying  quan- 
tities of  greenish  to  clear  watery  fluid  which  exhibits  all  the 
characteristics  of  gastric  juice.  The  chemical  tests  show 
the  presence  of  hj'drochloric  acid  and  pepsin.  The  micro- 
scope indicates  the  presence  of  epithelial  cells  and  leucocytes. 
The  violent  pains,  together  with  the  retching  and  vomiting, 
reduce  the  patient  to  a  condition  of  exhaustion.  There  is 
pronounced  pallor,  perspiration  is  free,  and  the  pulse  is 
feeble  and  rapid;  appetite  fails,  and  the  bow^els  are  torpid; 
the  urine  is  scanty  and  usually  alkaline  in  reaction.  The 
attacks  may  be  of  great  severity,  or  they  may  be  very  shght; 
their  duration  varies  from  one  or  two  hours  to  as  many  days. 
Convalescence  is  usually  rapid,  and  the  patient  may  feel 
well  enough  to  resume  his  occupation  the  day  following  the 
attack. 

Not  infrequently  the  seizures  are  accompanied  by  violent 
headaches.  Attacks  in  which  headache  is  a  prominent 
symptom  have  been  designated  by  the  special  term  "nervous 
gastroxynsis "  (Rossbach);  they  belong,  however,  to  the 
class  of  intermittent  hypersecretion.  Sometimes  the  cephal- 
algia is  of  such  a  character  that  the  local  gastric  disturbance 
is  obscured.  The  patient  may  feel  perfectly  well  during  the 
interval  between  the  seizures;  slight  gastric  discomforts, 
such  as  pressure,  fulness,  eructations,  are,  however,  experi- 
enced after  eating.  An  examination  of  the  stomach  con- 
tents during  the  interval  between  attacks  shows  an  excessive 
acidity,  which  would  indicate  the  possibility  of  a  coexistent 
chronic  hj^peracidity. 

Diagnosis. — The  diagnosis  is  confirmed  by  emesis  of  large 
quantities  of  liquid  which  responds  to  the  tests  for  gastric 
juice. 

Treatment.— When  the  physician  is  called  during  an  acute 
attack  of  hypersecretion,  it  is  his  first  duty  to  cut  short  the 
attack,  or,  failing  in  this,  to  mitigate  its  severity.  At  its 
onset  the  disease  may  be  diminished  in  severity,  or  even 


334  SECRETORY  NEUROSES 

aborted,  by  the  administration  of  large  doses  of  bicarbonate 
of  soda  or  magnesium  oxide.  Stomach  lavage  is  indicated 
either  with  clear  water  or  with  water  containing  nitrate  of 
silver  (1  to  1000).  The  drinking  of  milk  has  sometimes  a 
salutary  effect.  Should  the  attack  continue,  atropine,  1 
milligramme  {-^  grain),  is  indicated,  to  be  administered 
hypodermically.  This  is  the  most  reliable  medicament. 
Boas  recommends  morphine  and  atropine  in  combination, 
to  be  administered  subcutaneously.  Suppositories  of  extract 
of  belladonna  combined  with  morphine  are  useful,  but  do 
not  act  so  promptly  as  atropine  and  morphine  hypodermic- 
ally.  The  abdominal  pains  are  to  be  treated  with  hot 
compresses,  moist  or  dry.  No  food  should  be  taken.  Thirst 
should  be  allayed  by  small  pieces  of  ice  in  the  mouth. 
In  the  absence  of  distressing  symptoms  during  the  intervals 
between  the  attacks,  and  especially  if  the  secretion  of  hydro- 
chloric acid  be  normal,  a  bland  diet  may  be  prescribed. 
Irritating  food,  the  use  of  tobacco,  and  excessive  mental 
effort,  should  all  be  avoided.  If  the  patient  has  chronic 
hyperacidity  an  effort  should  be  made  to  counteract  this 
condition.  (See  chapter  on  Hyperacidity.)  Favorable  results 
are  frequently  obtained  in  nervous  patients  by  sojourn  in 
a  high  altitude.  In  some  cases  all  therapeutic  measures  fail 
to  prevent  a  recurrence  of  the  attacks. 


CHRONIC  GASTRORRHEA— REICHMANN'S  DISEASE 

In  this  form  of  hypersecretion,  first  described  by  Reich- 
mann,  the  stomach  secretes,  apparently  spontaneously,  at 
any  rate  without  the  stimulating  influence  of  food,  a  strong 
digestive  juice,  and  that  continuously.  Normally  only  a  few 
cubic  centimeters  of  fluid  contents  are  found  in  the  fasting 
stomach,  and  pepsin  and  hydrochloric  acid  are  either  absent 
or  present  in  minute  quantities.  In  cases  in  which  large 
(juantities  of  gastric  juice  are  found  regularly  on  removing 
the  contents  of  the  stomach  after  prolonged  abstinence  from 
food,  the  diagnosis  of  Reichmann's  disease  is  confirmed. 


CHRONIC  GASTRORRHEA  335 

Etiology. — Chronic  hypersecretion  may  develop  from  a  i^re- 
vioiisly  existing  hyperacidity,  which  explains  the  frequent 
simultaneous  occurrence  of  both  disease  processes.  In  such 
instances  hypersecretion  is  an  aggravated  form  of  hyper- 
acidity, in  which  the  secretory  and  sensitive  condition  of  the 
mucous  membrane  is  more  pronounced  than  in  cases  of 
uncomplicated  hyperacidity.  There  can  be  no  doubt  that 
nervous  influences,  too,  constitute  an  important  factor  in 
the  causation  of  hypersecretion.  The  majority  of  cases  of 
chronic  hypersecretion  occur  in  youth  and  middle  age,  and  in 
males.  The  secretion  of  gastric  juice  is  augmented  by  the 
abuse  of  alcohol  and  tobacco.  Among  the  causative  factors 
are  to  be  enumerated  dietetic  errors  and  mental  perturba- 
tions. Gastric  ulcer  is  also  a  cause  of  chronic  hypersecretion. 
The  frequent  coincidence  of  chronic  gastrorrhea  and  atony 
of  the  stomach  is  worthy  of  note.  Riegel  draws  attention  to 
the  possibility  of  a  relationship  between  hypersecretion  and 
the  traction  of  hernias  on  the  linea  alba,  the  peritoneum, 
and  the  stomach. 

Symptoms. — Chronic  hypersecretion,  or  Reichmann's  dis- 
ease, is  characterized  by  slow  onset,  with  mild  symptoms, 
pressure  and  fulness  after  eating,  eructations,  and  pyrosis. 
The  prodromes  are  those  of  chronic  gastritis.  The  symptoms 
may  disappear,  only  to  recur  in  aggravated  form.  Pain  is 
an  additional  symptom;  according  to  the  statements  of  the 
patient,  it  does  not  follow  the  ingestion  of  food.  Pains  may, 
however,  be  induced  by  partaking  of  food,  in  which  case 
they  occur  one  to  two  hours  after  eating,  or  occur  suddenly 
at  irregular  intervals.  Thus  the  pain  of  hypersecretion 
differs  from  that  of  hyperacidity,  which  usually  comes  on 
at  the  height  of  digestion.  The  fact  that,  the  stomach 
being  empty,  the  ingestion  of  food  while  the  pain  is  most 
severe  will  bring  relief,  is  of  diagnostic  importance.  At 
the  height  of  a  paroxysm,  vomiting  frequently  occurs,  and 
it  has  a  marked  effect  in  mitigating  the  severity  of  the  pains. 
The  greenish  watery  fluid  expelled  from  the  stomach  may 
amount  to  several  liters.  Hematemesis  is  sometimes  noted; 
when  it  is  present,  gastric  ulcer  or  erosions  of  the  stomach 


336  SECRETORY  NEUROSES 

should  be  borne  in  mind.  The  appetite  is  usually  fair,  but 
suffers  as  the  pains  become  more  persistent  and  severe. 
The  quantity  of  food  taken  by  the  patient  becomes  less  and 
less,  with  the  result  that  he  loses  weight  and  flesh.  In  pro- 
nounced cases  of  chronic  hypersecretion  the  patient  com- 
plains of  thirst,  the  bowels  are  constipated,  and  the  urine  is 
turbid  from  a  slight  degree  of  alkalinity. 

Many  cases  of  hypersecretion  are  complicated  with  atony 
and  motor  insufficiency  of  the  stomach.  Such  cases  are 
characterized  by  the  vomiting  of  large  quantities  of  fluid. 

Diagnosis. — On  the  removal  of  the  stomach  contents  in  a 
well-marked  case  of  hypersecretion  six  or  seven  hours  after 
a  test  meal,  there  are  found  large  quantities  of  food,  with 
no  meat  remnants,  but  residues  of  starchy  materials,  which 
are  precipitated  to  the  bottom  of  the  vessel.  The  total 
acidity  of  the  material  removed  is  very  high,  90  to  100,  and 
the  hydrochloric  acid  is  increased  from  50  to  70.  Sometimes, 
especially  in  cases  of  hypersecretion  accompanied  by  dilata- 
tion of  the  stomach,  the  contents  show  copious  evolution  of 
gas  in  the  fermentation  tubes  kept  in  the  incubator.  If  the 
stomach  be  carefully  cleansed  at  night  and  the  patient  per- 
mitted to  fast,  removal  of  the  stomach  contents  in  the  morn- 
ing will  show  varying  quantities  of  liquid  secretion  (up  to 
I  liter)  possessing  the  properties  of  gastric  juice.  A  positive 
finding  of  this  kind  serves  to  confirm  the  diagnosis  of  hyper- 
secretion. 

External  Examination  of  the  Stomach. — Palpation  reveals 
an  accelerated  peristaltic  motion.  A  thickened  pylorus  may 
be  sometimes  felt  by  the  palpating  hand,  inasmuch  as  the 
pyloric  exit  of  the  stomach  is  often  in  a  state  .of  tetanic 
contraction  induced  by  the  large  quantity  of  acid  present. 
As  soon  as  a  portion  of  the  acid  stomach  contents  passes 
through  into  the  small  intestine  the  pylorus  closes,  so  that 
it  is  impossible  for  the  stomach  to  properly  empty  itself. 
Each  relaxation  of  the  pylorus  is  followed  by  a  spasm  which 
blocks  the  exit.  The  muscles  of  the  stomach,  meanwhilo, 
attempt  to  force  a  passage  by  means  of  increased  peristaltic 
movements.     This  vicious  circle  is  the  cause  of  the  gastric 


CHRONIC  GASTRORRHEA  337 

dilatation  which  so  frequently  complicates  these  cases. 
Thickening  of  the  pylorus  may  be  the  result  of  an  old 
cicatrix  from  the  healing  of  a  gastric  ulcer. 

In  four  cases  of  hypersecretion  with  pylorospasm,  Rosen- 
stern  applied  continuous  saline  instillation — Murphy's  proc- 
toclysis— to  restore  the  needed  water  to  the  tissues.  He 
found,  to  his  surprise,  that  the  treatment  had  a  distinctly 
favorable  influence  on  the  spasm,  promoting  relaxation,  as 
evidenced  by  the  cessation  of  vomiting.  He  used  Ringer's 
solution,  a  mixture  of  7.5  parts  sodium  chloride,  0.42  part 
potassium  chloride,  and  0.24  part  calcium  chloride,  with 
1000  parts  water.  He  therefore  recommends  systematic 
continuous  enteroclysis  as  a  direct  means  of  influencing 
the  pylorospasm,  in  addition  to  its  other  advantages. 

Prognosis. — The  prognosis  for  complete  recovery  from 
chronic  hypersecretion  is  not  always  favorable.  Complete 
recovery  may  be  anticipated  only  in  that  class  of  patients 
who  are  in  a  position  to  continue  treatment  for  a  long  period 
of  time.  Patients  who  are  unable  to  take  the  necessary  care 
of  themselves  are  apt  to  have  relapses  after  intervals  of 
improvement. 

Treatment. — The  therapy  of  chronic  hypersecretion,  or 
Reichmann's  disease,  is  clearly  indicated  on  examination  of 
the  contents  of  the  stomach,  and  by  the  subjective  and  objec- 
tive symptoms.  Should  there  be  evidence  of  any  other 
pathologic  condition  complicating  or  maintaining  the  hyper- 
secretion, this  must  receive  due  consideration.  If  gastric 
ulcer  is  present  it  must  be  attended  to ;  and  the  neurasthenic 
requires  special  treatment.  Patients  suffering  from  hyper- 
acidity should  be  so  treated  as  to  preclude  the  possibihty  of 
transforming  that  condition  into  hypersecretion.  Anger, 
excitement,  mental  shock,  and  improper  diet  should  be 
avoided  as  much  as  possible.  Frequently,  however,  hyper- 
secretion would  seem  to  be  an  idiopathic  disease,  one  for 
which  there  is  no  assignable  cause. 

Diet. — The  chief  factor  in  the  therapeutics  of  hypersecre- 
tion is  a  properly  selected  dietary.  Since  the  quantity  of 
gastric  juice  secreted  during  the  period  of  digestion  is  abnor- 

22 


33S  SECRETORY  NEUROSES 

mally  large,  proteolysis  is  likely  to  be  satisfactory.  This  is 
attested  by  the  fact  that  when  the  stomach  contents  are 
removed  after  a  meal  of  meats  and  starches,  scarcely  any 
meat  remnants  remain;  the  residue  is  made  up  principally 
of  amylaceous  material.  The  gastric  digestion  of  carbo- 
hydrates is  held  completely  in  abeyance  in  hypersecretion, 
since  the  ptyalin  is  neutralized  almost  as  soon  as  the  food 
reaches  the  stomach.  From  this  it  follows  that  the  food 
should  be  mainly  protein.  So  far  as  the  quantity  of  fats 
in  the  food  is  concerned,  the  statements  regarding  fat  in 
hyperacidity  hold  good.  Fat  diminishes  the  secretion  of 
hydrochloric  acid,  and  should  therefore  be  employed  exten- 
sively in  the  treatment  of  hypersecretion.  A  diet  of  protein 
and  fat  is  indicated.  The  gastric  mucous  membrane  is  in 
a  condition  of  chronic  irritation;  therefore,  in  prescribing 
diet,  care  must  be  exercised  to  avoid  articles  of  food  which 
are  apt  to  aggravate  this  condition.  All  spices,  acids,  and 
highly  seasoned  foods  must  be  eliminated  from  the  diet. 
Extremes  of  temperature  in  foods  and  beverages  should  be 
avoided.  Thorough  mastication  of  the  food  is  an  important 
requirement;  the  food  should  be  in  a  finely  subdivided 
condition  before  being  swallowed. 

The  various  kinds  of  meat  may  be  taken  by  this  class 
of  patients.  Meats  should  be  well  cooked,  since  raw  meat 
combines  readily  with  acids  and  excites  the  secretion  of 
still  greater  quantities  of  gastric  juice.  Soft-boiled  eggs, 
scrambled  eggs,  omelet,  and  cream  cheese  are  indicated. 
Of  fats,  numerous  articles  merit  consideration;  for  example, 
butter,  olive  oil,  sesame  oil,  cottonseed  oil,  milk  and  cream, 
cocoa,  and  yolk  of  egg.  Milk  is  an  excellent  liquid  food ;  it 
is  non-irritant  and  has  a  neutralizing  effect  upon  the  acidity 
of  the  gastric  juice. 

Carbohydrates,  for  obvious  reasons,  should  be  restricted 
unless  they  have  been  dextrinized;  wheat  bread  should  be 
eaten  in  the  form  of  toast.  Crackers  and  zwieback  are  suit- 
able articles  of  diet.  Carbohydrates  should  be  given  in  the 
form  of  leguminous  flour  soups,  or  gruels,  or  as  sago  and 
oatmeal.  The  patient  ma}^  partake  of  a  small  ciuantity  of 
mashed  potatoes.     All  green  vegetables  should  be  prohibited. 


CHRONIC  GASTRORRHEA 


339 


Sugar  is  allowable  only  in  cases  in  which  the  motility  of  the 
stomach  is  normal,  since  it  may  give  rise  to  excessive  fer- 
mentation. Care  should  be  exercised  in  the  preparation  of 
dishes  for  this  class  of  patients,  to  avoid  even  a  moderate 
use  of  condiments. 

Diet  List  for  Hypersecretion  (Wegele) 


Carbo- 

Protein. 

Fat. 

hydrates 

Morning. 

100  Gm.  tea  with  milk     . 

3.4 

3.0 

4.8 

2  soft-boiled  eggs    . 

12.0 

10.0 

Forenoon. 

1.50  Gm.  calf's-foot  jelly  . 

.35.0 

17.0 

1.0 

Noon. 

150  Gm.  sweetbread  in 
bouillon 

.32.0 

2.50  Gm.  tapioca  mush 

12.0 

8.0 

11.0 

50  Gm.  cream 

2.0 

13.5 

1.7 

Afternoon. 

200  Gm.  milk        .      .      . 

6.8 

6.0 

9.6 

Evening. 

200  Gm.  ham   .      .      .      . 

48.0 

70.0 

2  scrambled  eggs     . 

12.0 

12.0 

At  meal  times. 

100  Gm.  aleuronat  toast  . 

28.3 

1.5 

66.7 

10  P.M.  and 

during  night. 

100  Gm.  milk   .      .      .      . 
Total      .      .      .      . 

6.5 

6.0 

10.0 

198.0 

147.0 

104.8 

Calories 

900 

1360 

430 

Entire  number  of  calories,  2700. 


Diet  List  for  Hypersecretion  (Friedenwald  and  Ruhrah) 

Calories. 

8  A.Ji.      200  Gm.  milk  flavored  with  tea 135 

2  soft-boiled  eggs '.      .  160 

60  Gm.  toa.st 1,54 

40  Gm.  butter        ...........  326 

10  a.m.        50  Gm.  raw  scraped  beef 60 

50  Gm.  toast 130 

12  M.  100  Gm.  broiled  steak 210 

Or  100  Gm.  chicken  or  lamb  chop. 

100  Gm.  asparagus 18 

Or  100  Gm.  carrots  (41)  mashed  and  strained. 
Or  100  Gm.  peas  (318)  mashed  and  strained. 
Or  100  Gm.  .spinach  (165). 

100  Gm.  stale  wheat  bread 258 

4  P.M.        200  Gm.  milk 135 

1  soft-boiled  egg 80 

60  Gm.  toast 1.54 

40  Gm.  butter 326 

7  p.m.        100  Gm.  baked  trout 106 

100  Gm.  milk 67 

2319 


340  SECRETORY  NEUROSES 

Nwiiber  of  Meals. — Regarding  the  number  of  meals,  a 
good  rule  to  follow  is  to  partake  of  food  at  comparatively 
frequent  intervals  and  in  small  quantities;  the  object  is  to 
make  use  of  the  gastric  juice  as  fast  as  it  is  secreted.  Fre- 
quent administration  of  food  wdll  tend  to  bring  about  an 
entire  cessation  of  pain;  suitable  articles  of  food  should  be 
at  hand  all  the  time.  Milk,  biscuits,  and  hard-boiled  eggs 
should  be  easily  accessible  to  the  patient  on  retiring  at  night; 
these  taken  at  the  beginning  of  a  pain  will  often  suppress  it. 

Liquids.— lAqmd^  should  be  taken  in  moderation,  since 
they  tend  to  increase  the  quantity  of  fluid  in  the  stomach. 
They  are  particularly  harmful  in  cases  of  hypersecretion 
combined  with  atony  or  dilatation.  Alcohol  and  coffee 
should  be  avoided.  When  there  is  great  thu'st,  and  it  is 
inadvisable  to  partake  of  sufficient  liquid  by  mouth  to  allay 
the  tliirst,  a  small  enema  (150  Cc.)  of  physiologic  salt  solu- 
tion will  satisfy  the  craving. 

In  severe  cases  of  hypersecretion  it  is  sometimes  advisable 
to  resort  to  rectal  feeding  for  a  period  of  eight  or  ten  days. 
By  this  means  irritation  of  the  stomach  by  food  \^'ill  be 
obviated,  and  a  diminished  secretion  of  gastric  juice  will 
result.  Riegel  suggests  an  exclusive  milk  diet  for  eight  or 
ten  days;  this  is  what  is  called  the  ''milk  cure."  Before 
prescribing  a  milk  diet,  however,  he  administers  a  milk 
test  breakfast  consisting  of  400  to  500  Cc.  of  milk.  The 
stomach  is  emptied  after  an  interval  of  an  hour.  Absence 
of  free  hydrochloric  acid,  though  the  total  acidity  be  high, 
warrants  a  trial  of  the  so-called  ''milk  cure."  The  milk  diet 
acts  as  a  sedative  to  the  sensory  nerve  endings  of  the  gastric 
mucous  membrane.  Intercurrent  diarrheas  may  be  pre- 
vented by  the  addition  of  lime  water  to  the  milk  in  the  pro- 
portion of  1  to  3  or  1  to  4.  The  feedings  should  consist  of 
350  to  400  Cc.  (12  to  14  ounces)  of  milk  every  two  hours, 
or  a  daily  amount  of  2800  Cc.  (about  3  quarts) .  This  regimen 
cannot,  however,  be  continued  for  more  than  eight  days. 
The  required  number  of  calories  may  be  attained  by  the 
addition  of  a  milk-cream  mixture  or  small  (luantities  of 
protein  preparations,  such  as  sanatogen,  plasnion,  roborat, 
or  nutrose. 


CHRONIC  GASTRORRHEA  341 

Medicinal  Treatment. — The  alkalies  are  valuable  therapeutic 
agents  in  the  treatment  of  hypersecretion,  as  well  as  in 
hyperacidity.  They  niciy  be  prescribed  to  be  taken  before, 
during,  or  after  the  ingestion  of  food.  Given  during  or 
before  a  meal,  the  alkalies  are  calculated  to  facilitate  amylo- 
lysis,  since  they  neutralize  the  free  hydrochloric  acid  which 
would  otherwise  put  a  stop  to  the  action  of  the  ptyalin  of 
oral  digestion  as  soon  as  it  reached  the  stomach. 

For  the  improvement  of  amylolysis,  artificial  saUvary  fer- 
ments have  been  employed.  One  of  these  is  the  artificial 
ptyalin  of  Merck.  This  preparation  may  be  given  with  the 
alkalies.  Again,  we  have  taka-diastase  and  malt  diastase; 
these  act  in  the  same  way  as  ptyalin.  Taka-diastase  is 
prepared  by  Parke,  Davis  &  Co.  from  the  aspergillus  oryzse, 
a  fungus  that  is  employed  in  Japan  in  the  manufacture  of 
rice  wine.  It  is  a  yellowish-white  powder,  soluble  in  water 
and  somewhat  more  resistant  to  the  action  of  acids  than  the 
other  varieties  of  diastase.  Taka-diastase  may  be  prescribed 
to  be  taken  with  the  food,  with  or  without  alkaUes,  in  cases 
of  hyperacidity  and  hypersecretion.  Like  ptyahn,  it  will  act 
as  a  starch  digestant  only  in  an  alkaline,  neutral,  or  slightly 
acid  medium.  Panase  is  a  pancreatic  preparation  similar  in 
its  action. 

Alkalies  are  given  after  meals  to  neutralize  excessive 
acidity  that  is  producing  painful  symptoms.  Large  doses 
have  the  effect  of  iiimiediately  relieving  the  pain.  They  are 
valuable  for  allaying  the  violent  paroxysmal  nocturnal  pains 
of  hypersecretion,  but  unfortunately  the  rehef  is  not  per- 
manent. Magnesium  oxide  and  bicarbonate  of  soda  are 
particularly  useful  in  these  conditions.  The  administration 
of  the  Carlsbad  salt  in  the  morning  after  the  night's  fast  is 
a  useful  procedure,  since  it  neutralizes  the  gastric  secretion 
and  washes  it  into  the  duodenum. 

Atropine  sulphate,  1  milligramme  (eV  grain),  has  been 
given  hypodermically  during  violent  pylorospastic  attacks. 
Eumydrin  also  can  be  used,  and  is  safer.  Favorable  results 
have  been  secured  from  the  use  of  extract  of  belladonna  in 
suppository  form.  This  drug  may  also  be  given  internally, 
either  alone  or  in  combination  with  the  alkalies. 


342  SECRETORY  NEUROSES 

Astringent  remedies  are  to  be  employed  as  in  the  treatment 
of  hyperacidity.  Preparations  of  bismuth  or  nitrate  of 
silver  may  be  given  by  mouth  in  combination  with  atropine. 

Jaworski  recommends  in  the  treatment  of  hypersecretion 
two  alkaline  waters,  a  stronger  and  a  weaker.  The  stronger 
consists  of  1  hter  of  water  charged  with  carbon  dioxide, 
sodium  bicarbonate  8  Gm.,  sodium  salicylate  2.5  Gm., 
sodium  borate  2  Gm. ;  the  weaker  water  contains  sodium 
bicarbonate  5  Gm.,  sodium  salicylate  2  Gm.,  sodium  borate 
1  Gm. ;  the  dose  is  a  half -glass  to  a  full  glass  after  each 
meal,  depending  upon  the  condition  of  the  secretion.  If 
constipation  be  present,  Jaworski  employs  two  solutions  of 
effervescent  magnesia,  a  milder  and  a  stronger.  The  milder 
is  as  follows :  . 

Gm.  or  Cc. 

I^ — Magnesii  carbonatis 4.0         3] 

Magnesii  salicylatis 1.0         gr.  xv 

Aquae  carbonis  dioxidi  .       q.  s.  ad    1000.0         Oij 

Misce. 

Sig. — One-fourth  to  one-half  tumblerful  fifteen  to  thirty  minutes  after 
each  meal. 

The  stronger  solution  is  as  follows : 

Gm.  or  Cc. 

I^— Magnesii  carbonatis 10.0        oiiss 

Sodii  chloratis 4.0        oj 

Aquse  carbonis  dioxidi 1000.0         Oij 

Misce. 

Sig. — One  to  one  and  one-half  tumblerfuls  in  the  morning  on  an  empty 
stomach,  or  in  the  evening  at  bedtime. 

Treatment  by  Lavage  of  the  Stomach. — In  cases  of  hypersecre- 
tion where  the  symptoms  do  not  yield  to  dietary  and  drug 
therapeutics,  the  stomach  should  be  washed  out  just  before 
the  evening  meal.  It  is  then  in  a  condition  to  receive  and  to 
digest  a  small  supper.  The  quantity  of  acid  secreted  after 
the  supper  is  neuti-alizod  by  the  food.  Lavage  is  also  indi- 
cated in  the  morning  ])efore  breakfast,  to  remove  the  acid 
secreted  during  the  early  morning  liours,  as  well  as  llu>  rem- 
nants of  food  that  may  have  remained  ovornight  in  tlie 
stomach.     In  pronounced  cases  of  hypersecretion,   lavage 


ALIMENTARY  HYPERSECRETION  343 

at  these  two  periods  is  imperative;  painful  attacks  are  often 
cut  short  by  a  single  washing.  Pure  water,  lukewarm,  is 
employed  in  the  process,  to  be  followed  by  lavage  with  a 
mild  alkali,  such  as  sodium  bicarbonate.  Lavage  with 
1-to-lOOO  nitrate  of  silver  or  with  a  suspension  of  bismuth 
subnitrate  has  been  employed  with  good  success.  Penzoldt 
advises  the  drinking  of  half  a  liter  of  a  1-per-cent.  solution 
of  boric  acid,  which  is  to  be  removed  from  the  stomach  after 
five  minutes. 

Treatment  with  Mineral  Waters. — Carlsbad  water,  taken  in 
large  doses  and  for  a  long  period  of  time,  has  the  effect  of 
diminishing  the  secretion  of  gastric  juice.  It  is  favorable 
to  the  peristaltic  movements  of  the  stomach  and  tends  to 
diminish  the  sensitiveness  of  that  organ.  The  waters  of 
Bertricho  are  similar  in  action  to  the  Carlsbad  waters. 
Instead  of  Carlsbad,  Vichy  water  may  be  prescribed  for 
neurotic  patients. 

Physical  Treatment. — Massage,  vibration,  and  electric  treat- 
ment must  not  be  employed  in  hypersecretion.  Hydro- 
therapeutic  and  thermic  applications  may,  however,  be  made 
extensively  and  to  good  advantage.  Hot  compresses,  moist 
or  dry,  applied  locally,  are  particularly  adapted  to  the  treat- 
ment of  painful  seizures.  Winternitz  applied  running  hot 
water,  104°  F.,  over  cold  and  moist  abdominal  packs  by 
means  of  a  rubber  tube  (Fig.  20) .  According  to  this  authority 
the  local  heat  deadens  the  chilly  sensation  of  the  cold  wet 
cloth  enveloping  the  body,  as  a  stronger  nerve  stimulus 
deadens  a  less  intense  one.  In  severe  cases  prolonged  rest 
in  bed  is  essential. 

Surgical  Treatment. — In  cases  of  hypersecretion  complicated 
with  atony  of  the  second  degree,  marked  motor  disturbances, 
and  stenosis  of  the  pylorus,  gastroenterostomy  may  prove 
of  permanent  benefit. 

ALIMENTARY  HYPERSECRETION 

Alimentary  hypersecretion  is  a  less  severe  variety  of 
chronic  gastrorrhea.      While  in   Reichmann's   disease   the 


344  SECRETORY  NEUROSES 

gastric  mucous  membrane  is  in  a  state  of  continuous  irri- 
tability, as  a  result  of  which  the  gastric  secretion  is  con- 
stant and  abnormal  in  quantity,  even  when  the  stomach 
is  empty,  in  alimentary  hypersecretion  the  symptoms, 
which  afford  the  same  clinical  picture  when  thej^  appear, 
are  only  induced  by  stimulation  of  the  gastric  mucous  mem- 
brane. There  must  be  a  stimulus,  however  sUght,  before 
the  abnormal  secretion  begins.  Much  less  stimulation 
is  required,  however,  than  in  the  normal  stomach;  the 
secretion  begins  sooner.  This  variety  of  hypersecretion  has 
been  described  by  Zweig  and  Calvo,  Strauss,  Riegel,  and 
Boas. 

Symptoms. — The  subjective  symptoms  are  less  severe  than 
those  of  chronic  gastrorrhea,  resembUng  more  closely  those 
of  hyperacidity.  Gastric  discomforts,  consisting  of  pjTosis, 
pressure,  acid  eructations,  and  pain  of  greater  or  less  severity, 
set  in  almost  immediately  after  food  is  partaken.  In  this 
way  is  alimentary  hypersecretion  differentiated  from  hj^per- 
acidity,  the  symptoms  of  which  do  not  appear  until  some 
little  time  after  eating.  In  contrast  with  hyperacidity,  the 
discomforts  of  alimentary  hypersecretion  are  not  diminished 
by  partaking  of  food.  The  appetite  is  generally  good, 
though  patients  often  become  poorly  nourished  because  they 
are  afraid  to  eat.  When  alimentary  hypersecretion  is  com- 
plicated with  motor  disturbances,  the  distressing  symptoms 
are  in  proportion  to  the  time  the  food  remains  in  the  stomach. 
In  intense  attacks  of  pain,  as  in  Reichmann's  disease,  con- 
stipation is  a  frequent  concomitant  symptom. 

Diagnosis. — Palpation  of  the  empty  stomach,  as  a  rule,  does 
not  reveal  anything  of  note.  When  the  stomach  is  filled 
with  food,  palpation  occasionally  causes  a  sUght  degree  of 
pain.  Splashing  sounds  can  be  elicited  occasionally  during 
the  height  of  digestion,  especially  if  atony  be  present.  The 
diagnosis  must  be  made  by  means  of  the  test  meal  or  test 
breakfast.  The  facts  that  the  fluid  portion  exceeds  the 
solid  residues,  and  that  the  total  quantity  of  fluid  removed  is 
greater  than  the  amount  introduced,  are  of  diagnostic 
importance.     The  quantity  of  free  hydrochloric  acid  will 


ALIMENTARY  HYPERSECRETION  345 

be  found  above  normal.  There  are  no  pathologic  findings 
which  can  be  said  to  be  pathognomonic  of  this  disease. 

Treatment. — The  dietetic  treatment  is  the  same  as  that 
prescribed  for  Reichmann's  disease.  Owing  to  the  fact  that 
amylolysis  is  deficient,  the  food  should  be  chiefly  of  a  pro- 
tein and  fatty  nature.  It  should  be  finely  subdivided,  pref- 
erably mucilaginous  in  consistency;  and  the  meals  should 
be  hmited  to  three  a  day  and  taken  at  regular  intervals, 
so  as  to  prevent,  to  the  greatest  possible  extent,  irritation 
of  the  gastric  mucous  membrane.  In  these  cases,  too,  it 
is  sometimes  expedient  to  place  the  patient  on  an  exclusive 
milk  diet,  keeping  him  in  bed.  Milk  should  be  given  at 
long  intervals,  for  the  same  reason  that  sohd  food  is  widely 
spaced. 

Medicinal  Treatment. — Alkalies  are  to  be  employed  exten- 
sively, both  before  and  during  meals,  to  assist  amylolysis, 
and  also  after  meals  and  at  the  height  of  digestion.  Atropine 
sulphate,  hypodermically,  by  mouth,  or  by  suppository,  is 
of  value  when  there  is  pain.  Occasionally  it  is  necessary  to 
continue  the  administration  of  atropine  over  an  extended 
period.     Astringents  are  also  indicated. 

Treatment  by  Lavage  of  the  Stomach. — The  best  time  for  this 
procedure  in  cases  of  alimentary  hypersecretion  is  late  at 
night,  after  an  early  supper,  in  order  to  relieve  the  stomach 
of  food  remnants  and  thus  prevent  gastric  secretion  during 
the  night.  Lavage  with  pure  water  may  be  succeeded  by 
lavage  with  alkalies  or  with  nitrate  of  silver  (1  to  1000). 


CHAPTER    XVI 

ACUTE  GASTRITIS:    SIMPLE— INFECTIOUS— TOXIC— 
PHLEGMONOUS 

Acute  gastritis  (acute  gastric  catarrh)  is  an  inflammation 
of  the  gastric  mucous  membrane  accompanied  by  disturb- 
ances of  digestion.  The  inflammation  may  be  simple,  infec- 
tious, toxic,  or  phlegmonous.  It  may  be  limited  to  the 
superficial  layer  of  the  gastric  mucosa,  or  it  may  involve  the 
glandular  epithelium,  the  parenchyma,  or  the  interstitial 
tissues. 

SIMPLE  ACUTE  GASTRITIS 

This  is  the  form  of  gastritis  that  is  most  frequently  met 
in  general  practice.     No  age  or  class  is  exempt. 

Etiology. — Among  the  etiologic  factors  are:  errors  in  diet — 
an  excessive  amount  of  food  taken  at  one  time;  mechanical, 
thermic,  or  chemic  irritants ;  foods  highly  spiced  or  fermented; 
unripe  or  over-ripe  fruits;  cold  drinks,  soda  water,  and  ice 
cream;  food  in  process  of  decomposition;  the  excessive  use 
of  condiments;  and  overindulgence  in  alcohol. 

The  tendency  to  acute  gastritis  is  greater  in  some  individ- 
uals and  families  than  in  others.  In  many  persons  the 
predisposition  is  such  that  the  slightest  excess  in  diet  pre- 
cipitates the  catarrhal  condition.  In  this  class  are  anemic 
women,  invalids,  and  elderly  persons.  Acute  gastritis  may 
be  secondary  to  other  affections,  as  the  acute  infectious 
diseases,  typhoid,  smallpox,  pneumonia,  or  measles. 

Lebert  and  Oser  urge  the  infectious  nature  of  the  disease, 
but  no  microorganisms  have  been  found  within  the  stomach 
to  substantiate  this  claim. 

Toxic  gastritis  in  its  milder  forms  may  be  placed  in  the 
category  of  simple  acute  gastritis.     Decom]ioRition  products, 


SlMl'LE  ACL'TE  GASTRITIS  347 

such  as  spoiled  food,  meat,  fish,  or  cheese,  are  coiitril^utory 
to  this  form  of  gastric  catarrh.  With  acute  gastritis  may 
be  classed  the  light  forms  of  acute  infectious  gastritis  caused 
b}^  microorganisms  introduced  with  decomposed  food.  It 
is  well  known  that  parasites,  oxyuris,  teniae,  ascarides,  and 
larv*  of  flies,  taken  into  the  stomach,  may  cause  gastritis. 

Pathology. — The  gastric  mucosa  is  wholly  or  partially 
swollen  and  reddened,  the  inflamed  portions  covered  with 
tenacious  mucus.  In  occasional  instances  there  are  slight 
hemorrhages.  The  submucosa  may  be  edematous.  Micro- 
scopically, the  surface  epithelium  appears  altered;  it  is 
swollen,  opaque,  and  desquamated.  Similar  changes  are 
noted  in  the  glandular  epithelium.  The  capillaries  are 
markedly  dilated  and  congested.  Round-celled  infiltration 
is  occasionally  found  in  the  interstitial  tissue. 

Symptoms. — In  mild  forms  of  gastric  catarrh,  due  to 
dietetic  errors,  the  patients  complain  of  a  feeling  of  weight  in 
the  pit  of  the  stomach,  followed  by  a  sensation  of  fulness. 
Belching  affords  relief.  In  some  cases  there  is  nausea,  and 
in  the  more  severe  type  of  acute  gastritis  the  onset  of  the 
disorder  is  characterized  by  gastric  pains,  nausea  and 
vomiting,  rise  of  temperature,  loss  of  appetite,  and  consti- 
pation or  diarrhea.  The  vomited  material  usually  consists 
of  bad-smelling  and  fermented  masses,  acid  in  reaction.  The 
total  acidity  of  the  vomited  material  varies;  free  hydro- 
chloric acid  is  usually  decreased  or  absent.  On  the  other 
hand,  in  some  cases  there  is  hyperacidity  and  hypersecre- 
tion accompanied  by  pyrosis.  A  high  total  acidity  is  occa- 
sionally caused  by  the  presence  of  the  organic  acids — acetic 
and  butyric.  Emesis,  or  retching  after  the  stomach  has 
been  emptied,  often  results  in  the  evacuation  of  mucobiliary 
masses.  The  tongue  is  coated  and  the  breath  fetid.  The 
region  over  the  stomach  is  sensitive  to  pressure,  and  the 
stomach  shows  a  slight  distention.  Acute  gastritis  may  be 
afebrile,  or  there  may  be  a  temperature  of  102°  to  104°  F. 

Course. — The  course  of  acute  gastritis  depends  largely 
upon  the  intensity  of  the  attack;  its  usual  duration  is  from 
one  to  three  days.     An  early  emesis  gives  great  relief,  so 


348  ACUTE  GASTRITIS 

that  the  distressing  symptoms  often  rapidly  subside.  Some- 
times, however,  vomiting  is  followed  by  lassitude,  weakness, 
and  cephalalgia.  Acute  gastric  catarrh  may  pass  from  the 
stomach  to  the  intestine,  involving  both,  so  that  we  have  a 
gastroenteritis.  Though  patients  usually  recover  from  mild 
attacks  in  two  or  three  days,  the  so-called  ''weak  stomach  " 
remains,  and  the  patient  has  more  or  less  prolonged  periods 
of  anorexia. 

Prophylaxis. — Persons  subject  to  attacks  of  acute  gastric 
catarrh  should  be  on  their  guard  against  dietary  mdiscretions. 
They  should  avoid  rich  foods,  food  that  is  either  too  cold 
or  too  hot,  unripe  fruits,  and  whatever  may  have  been  impli- 
cated in  causing  previous  attacks.  Were  patients  to  avoid 
such  articles  of  diet,  and  refrain  from  habits  and  excesses 
known  to  themselves  to  be  causative  factors  in  acute  gastric 
catarrh,  this  disease  could  be  prevented  to  a  very  marked 
degree. 

Treatment. — The  vis  medicatrix  naturce  is  seen  at  its  best 
in  this  affection.  To  get  rid  of  the  undigested  material,  the 
stomach  empties  itself  by  vomiting,  or  by  passing  the  con- 
tents on  to  the  small  intestine,  where  they  may  set  up  a 
diarrheal  discharge. 

When  vomiting  does  not  take  place  from  the  irritation 
caused  by  the  mass  of  undigested  food  in  the  stomach,  we 
should  lend  our  assistance  to  bring  about  evacuation  of  the 
stomach  contents.  The  first  question  is:  Shall  we  give  an 
emetic?  Emetics  are  nowadays  rarely  emploj^ed,  perhaps  not 
so  often  as  they  should  be.  In  acute  gastric  catarrh  they 
should  not  be  thought  of  unless  there  is  a  sense  of  fulness 
and  distress  in  the  epigastrium,  with  an  inclination  to  vomit. 
A  glass  of  warm  water  containing  mustard  may  be  given. 
Sometimes  emesis  may  be  induced  by  simply  tickling  the 
fauces.  In  the  great  majority  of  cases  vomiting  has  occurred 
before  the  arrival  of  the  physician,  and  the  indication  is  to 
relieve  excessive  irritability. 

The  best  method  of  cleansing  the  stomach  is  by  the  use 
of  the  stomach  tube.  Since  the  object  is  not  medication, 
but  simply  mechanical  elimination,  it  is  suflicient  to  wash 


SIMPLE  ACUTE  GASTRITIS  349 

out  the  stomach  with  hikewarm  water  to  which  bicarbonate 
of  soda,  a  teaspoonful  to  the  pint,  has  been  added.  This 
will  promote  the  solution  of  mucus.  It  is  always  wise  to 
evacuate  the  stomach  by  means  of  the  stomach  tube  when 
evacuation  is  desirable  and  does  not  occur  spontaneously. 
Many  patients  are  afraid  of  the  tube,  and  protest  at  the  mere 
mention  of  it;  but  it  is  the  duty  of  the  physician  so  to  train 
himself  in  its  manipulation  that  he  can  use  it  with  the  mini- 
mum of  discomfort  to  the  patient.  I  strongly  commend  the 
use  of  the  stomach  tube  for  promptness  and  thoroughness 
in  the  evacuation  of  stomach  contents;  it  has  the  additional 
advantage  that  it  does  not  irritate  the  gastric  mucosa  as  do 
emetics  given  by  mouth.  In  performing  lavage,  the  patient 
should  be  instructed  to  occupy  different  positions  to  facilitate 
the  thorough  cleansing  of  the  stomach.  Some  authors  recom- 
mend the  addition  of  hydrochloric  acid  in  order  to  destroy 
ferment.ative  organisms.  Usually  a  single  lavage  is  sufficient 
if  it  be  thoroughly  done.  In  children,  lavage  is  the  only 
method  of  cleansing  the  stomach  that  should  be  considered. 
In  infants  and  very  young  children  it  may  be  accomphshed 
by  means  of  a  Nelaton  catheter. 

After  lavage  the  retching  ceases  and  the  general  condition 
improves.  It  is  evident  that  gastritis  cannot  be  cured  so 
long  as  decomposed  food  materials  remain  in  the  stomach. 
Emetics  proper  remain  for  those  cases  in  which,  for  one  or 
another  reason,  it  is  impossible  or  impracticable  to  use  the 
stomach  tube.     The  most  useful  emetic  is : 

Gm.  or  Cc. 

I^ — ^Antimonii  et  potassii  tartratia 0 .  05  gr.  j 

Pulvis  radicis  ipecacuanhge 1 .  00  gr.  xv 

Misce  et  ft.  pulv.  no.  v. 

Sig. — One  powder  every  quarter  of  an  hour  until  vomiting  occurs. 

The  following  may  be  administered  to  children: 

Gm.  or  Cc. 

I^ — Pulvis  radicis  ipecacuanhaj 2.0  Sss 

Syrupus  amygdalae 20.0  5v 

Misce. 

Sig. — One  dessertspoonful  every  ten  minutes  until  vomiting  is  induced. 


350  ACUTE  GASTRITIS 

When  the  administration  of  emetics  by  mouth  is  inad\'is- 
able,  on  account  of  its  tendency  to  increase  the  irritable 
condition  of  the  stomach,  the  hypodermic  injection  of 
apomorphine  may  be  resorted  to: 

Gm.  or  Cc. 

R — Apomorphinae  hydrochloridi 0.1  gr.  iss 

Aquae  destillatae 10.0  oiiss 

Misce. 

Sig. — One-half  to  one  syringeful  hj-podermically  (7  to  15  minims). 

Hypodermic  tablets  of  apomorphine  ready  for  use  are  to 
be  had,  and  fresh  supphes  should  be  carried  in  the  regular 
medicine  case.  The  action  of  apomorphine  is  rapid  and 
certain. 

After  the  stomach  has  been  thoroughly  emptied  and 
cleansed,  all  food  should  be  interdicted  for  the  next  twenty- 
foui:  to  forty-eight  hours.  This  edict  \\dll  not  be  difficult  to 
enforce,  since  the  patients  have  httle  or  no  appetite.  Thirst 
may  be  allayed  by  means  of  cracked  ice.  Carbonated  waters, 
iced  milk,  brandy  and  soda,  and  lemonade  are  acceptable 
and  generally  harmless. 

Preparations  containing  menthol  quiet  and  anesthetize 
the  hypersensitive  mucosa,  acting  at  the  same  time  as  anti- 
septics: 

Gm.  or  Cc. 
R— Mentho!i.s 1.0  gr.  xv 

Alcoholi.s, 

Syrupi aa     30.0  oj 

Misce. 

Sig. — One  tea.spoonful  every  hour. 

Validol  is  a  good  substitute  for  menthol.  It  is  a  prepa- 
ration of  menthol  and  valerianic  acid,  containing  about  30 
per  cent,  of  free  menthol.  It  may  be  prescribed  to  be  taken 
three  times  a  day  in  doses  of  0.6  to  1  Cc.  (10  to  15  minims). 

Bicarbonate  of  soda,  either  alone  or  with  such  antizymotics 
as  resorcinol  and  salicylic  acid,  may  be  given,  should  the 
contents  of  the  stomach  be  markedly  acid: 

Gm.  or  Cc. 
I^ — Rfsorfinoli.s 0.6  gr.  x 

Sodii  bicarbonalis, 

Bismuthi  salioylatis fia       4.0  5i 

Misce  et  ft.  pulv.  no.  x. 

Sig. — One  powder  oven,-  two  hours. 


SIMPLE  ACUTE  GASTRITIS  351 

The  coated  tongue  may  be  carefully  cleansed  mechanic- 
ally by  means  of  a  clean  piece  of  soft  linen  moistened  with 
lemon  juice. 

A  marked  degree  of  pyrosis  can  be  relieved  by  the  follow- 
ing: 

Gm.  or  Cn. 

I^ — INIagnesii  oxicli, 

Sodii  bicarbonatis, 

Olei  sacchari  menthaj  piperitae    .      .      .      .   aa     10.0         3iiss 
Misce  et  ft.  pulv. 
Sig. — Knife-pointful  every  two  hours. 

For  the  rehef  of  pain :  • 

Gm.  or  Cc. 

I^ — Codeinse  phosphatis 0.12       gr.  ij 

Aquae  menthte  piperitse 30.0        §  j 

Misce. 

Sig. — One  teaspoonful  twice  or  three  times  a  day. 

For  acid  eructations: 

Gm.  or  Cc. 
I^ — Resorcinolis 1.0         gr.  xv 

Aquae  destillatae, 

Aquae  menthae  piperitae aa     4.5.0         §iss 

Misce. 

Sig. — One  tablespoonful  every  two  hours. 

Diet. — After  twenty-four  to  forty-eight  hours'  rest,  liquid 
food  (no  other)  should  be  given — soups  and  gruel  in  small 
but  gradually  increasing  quantities.  The  yolk  of  an  egg 
may  be  added  to  the  soup.  Later,  this  diet  may  be  follow^ed 
by  milk  sipped  slowly,  fowl,  minced  ham,  crackers,  eggs, 
and  filet  of  beef.  This  is  usually  sufficient  for  an  ordinary 
case  of  simple  acute  gastritis.  Should  the  appetite  continue 
poor,  it  may  be  stimulated  by  tablespoonful  doses  of  1  to  1| 
per  cent,  common  salt  solution,  by  port  wine,  or  by  caviar; 
or  hydrochloric  acid  dilute,  1  Gm.  (15  minims),  may  be 
given  before  meals  in  lemonade  or  compound  tincture  of 
cinchona.  Fluidextract  of  condurango,  1  Gm.  fl5  minims) 
thi'ee  times  a  day,  before  meals,  has  a  good  effect. 

Pain  is  sometimes  complained  of,  though  it  is  rareh^  of 
such  intensity  as  to  require  treatment.     Moderate  pains  and 


352  ACUTE  GASTRITIS 

gastric  pressure  are  best  treated  by  hydriatic  measures. 
A  Priessnitz  bandage,  renewed  every  two  or  three  hours, 
is  of  good  service  in  such  cases.  Should  the  pains  be  more 
severe,  moist  appUcations  or  hot  dry  compresses,  hot  bottles 
or  the  electric  pad  are  indicated.  These  apphances  may 
be  continued  for  some  time  if  necessary.  The  consideration 
of  analgesic  and  narcotic  remedies  must  be  reserved  for 
cases  accompanied  by  excessive  pain;  these  drugs  must  not, 
however,  be  given  by  mouth,  but  should  be  administered  in 
suppository  form  only:  Extract  of  opium,  0.03  to  0.05  Gm. 
(h  to  1  grain) ;  codeine  phosphate,  0.03  to  0.05  Gm.  (h  to  1 
grain) ;  codeine,  0.05  Gm.  (1  grain) ;  extract  of  belladonna, 
0.03  Gm.  (i  grain),  alone  or  in  combination,  are  the  drugs 
employed. 

Morphine  is  apt  to  induce  vomiting. 

The  intestinal  tract  may  be  affected  in  acute  gastric 
catarrh  by  the  presence  of  irritating  substances  from  the 
stomach,  so  that  instead  of  a  simple  acute  gastritis  we  have 
an  acute  gastroenteritis.  When  there  is  reason  to  suspect 
the  presence  of  decomposed  and  irritating  masses  in  the 
intestine,  it  is  good  treatment  to  induce  evacuation.  Calo- 
mel is  the  best  remedy  we  have  for  this  purpose.  It  is  an 
excellent  remedial  agent  in  the  treatment  of  gastrointestinal 
disorders  of  children.  The  dose  for  adults  is  0.12  Gm. 
(2  grains)  twice  a  day,  or  0.01  Gm.  (|  grain)  every  hour  for 
ten  doses.  Castor  oil  is  also  a  useful  evacuant.  Patients 
who  cannot  take  castor  oil  will  readily  take  Carlsbad  salt, 
5  Gm.  (3j)  in  a  half-glass  of  water;  it  should  be  taken  in 
the  morning  when  the  stomach  is  empty.  After  thorough 
evacuation  of  the  bowels,  three  or  four  days  may  elapse 
before  the  next  movement.  Should  constipation  persist,  an 
enema  of  warm  water,  plain  or  containing  soap,  oil,  glycerin, 
vinegar,  soda,  or  cottonseed  oil,  should  be  given.  After 
cleansing  the  intestine,  such  intestinal  disinfectants  as 
resorcinol  or  salicylate  of  bismuth  may  be  considered. 


ACUTE  INFECTIOUS  GASTRITIS  353 

ACUTE  INFECTIOUS  GASTRITIS   (INFECTIOUS   CATARRH 
OF  THE  stomach) 

Gastric  catarrh  may  occasionally  assume  what  is  known 
as  a  grave  form. 

Etiology. — Usually  the  exciting  cause  of  infectious  gastric 
catarrh  consists  of  microorganisms  introduced  into  the 
stomach  with  articles  of  food,  decomposed  meat  or  fruit, 
or  food  or  drink  which  may  not  appear  to  be  tainted,  such 
as  impure  milk  or  water  from  infected  wells.  The  grave 
form  of  acute  gastric  catarrh  may  thus  become  epidemic. 
It  is  often  a  very  difficult  matter  to  determine  the  cause  of 
this  disease  with  absolute  certainty. 

Pathology. — The  pathologic  changes  accompanying  the 
three  forms  of  acute  gastritis  are  similar  to  those  of  the  mild 
form;  the  difference  is  one  of  degree  only.  There  is  marked 
hyperemia,  tumefaction  and  reddening  of  the  gastric  mucosa, 
with  marked  participation  of  the  glandular  epithehum  and 
interstitial  tissue. 

Symptoms. — The  symptoms  described  in  the  section  on 
Acute  Gastric  Catarrh  are  present  here  in  aggravated  form, 
consisting  of  violent  pains  accompanied  by  persistent  and 
severe  vomiting  and  marked  prostration.  Fever,  always 
absent  in  mild  gastric  catarrh,  is  a  constant  symptom  of 
the  grave  variety.  In  fact,  the  febrile  disturbance  is  a 
fairly  reliable  index  of  the  gravity  of  the  disease.  These 
severer  forms  of  acute  gastritis  are  sometimes  due  to  dietary 
indiscretions;  but  they  are  more  frequently  the  result  of 
infection,  so  that  this  form  of  the  disease  is  designated  acute 
infectious  gastric  catarrh.  Every  acute  infectious  catarrh, 
however,  is  not  grave. 

The  fever  (gastric  fever)  is  of  marked  intensity  and  of 
the  continued  or  remittent  type.  Other  symptoms  are: 
violent  throbbing  headache,  insomnia,  thirst,  rapid  pulse, 
and  occasional  delirium.  In  the  febrile  cases  there  is  a 
marked  diminution  of  acid  secretion;  the  fever  itself  in  all 
probability  reduces  the  secretion  of  hydrochloric  acid.     The 

23 


354  ACUTE  GASTRITIS 

disease  ordinarily  runs  from  ten  to  fourteen  days;  in  some 
instances  the  fever  may  persist  for  three  weeks.  In  very 
old  and  very  young  patients  this  form  of  gastritis  may  assume 
an  alarming  character. 

The  severe  forms  of  infectious  gastritis  exhibit  clinical 
symptoms  similar  to  those  that  are  caused  by  the  introduction 
into  the  stomach  of  organic  poisons,  such  as  the  metabolic 
products  of  infectious  microorganisms — toxins  and  ptomains. 
The  course  of  the  disease  is  usually,  but  not  always,  severe. 

Treatment. — The  treatment  of  these  severe  forms  of  acute 
gastric  catarrh  is  based  upon  the  same  principles  as  that  of 
the  milder  forms.  The  stomach  must  be  emptied  and 
cleansed  as  quickly  and  thoroughly  as  possible  by  means 
of  lavage.  When  the  disease  is  due  to  infection  it  is  well 
to  wash  out  the  stomach  with  antiseptic  solutions:  for 
example,  salicylic  acid  1  to  2  parts  in  1000  of  w^ater,  or  dilute 
boric  acid  solution  (3  to  1000  to  5  to  1000).  Emetics  should 
not  be  employed  if  it  is  possible  to  empty  the  stomach  in 
any  other  way.  Food  should  be  interdicted  for  a  number 
of  days  in  the  case  of  robust  patients,  to  give  the  stomach 
needed  rest.  Thirst  and  persistent  vomiting  are  to  be  met 
by  small  doses  of  cold  mineral  waters,  carbonated  waters 
either  with  or  without  fruit  juices,  cracked  ice,  or  cold  tea. 
The  general  condition  of  the  patient,  his  pulse  and  tempera- 
ture, must  be  constantly  under  observation.  Wine,  brandy, 
cognac,  champagne,  Tokay  wine  and  strong  coffee  are  to  be 
administered  to  the  aged  and  weak  as  indicated. 

When  a  patient  is  in  a  condition  to  partake  of  food,  partic- 
ular care  should  be  exercised  in  regard  to  the  kind  and  quan- 
tity permitted.  At  first  onlj^  liquid  foods,  such  as  bouillon 
with  yolk  of  egg,  meat  juices  and  extracts,  albumin  water, 
and  leguminous  soups,  should  be  allowed.  Should  obstinate 
vomiting  interfere  with  eating,  nutritious  enenuita  may  be 
given.  Great  caution  should  bo  exercised  when  the  patient 
is  passing  from  liquid  to  solid  food.  The  initial  solids 
should  consist  of  veal,  sweetbread,  brain,  boiled  fowl  (chicken. 
S(iuab),  minced  raw  meat,  minced  ham,  meat  jelly,  flour  and 
milk  gruel,   tapioca,  mashed  potatoes,  milk,  crackers,   or 


TOXIC  GASTRITIS  355 

zwieback.  The  return  to  a  full  diet  should  be  very  gradual, 
not  complete  until  ten  to  fourteen  days  after  the  cessation 
of  all  the  symptoms. 

Medicinal  Treatment.  —  The  same  drugs  prescribed  in 
the  treatment  of  milder  gastric  catarrh  are  indicated  in  the 
infectious  forms.  Since  in  these  severe  acute  cases  the 
hydrochloric  acid  secretion  is  diminished,  dilute  hydro- 
chloric acid  should  be  given  three  times  a  day  in  doses  of 
0.75  to  1  Gm.  (10  to  15  minims),  well  diluted  wdth  water. 
This  will  serve  the  additional  purpose  of  allaying  the  thirst. 
Resorcinol  may  be  given  for  nausea  and  bad-smelUng 
eructations.  Persistent  vomiting  is  combated  by  the  use 
of  menthol,  or  by  Potio  Riveri  (citric  acid  2  Gm.,  bicarbonate 
of  soda  3  Gm.,  w^ater  100  Cc),  to  which  may  be  added 
cocaine,  0.065  Gm.  (1  grain);  this  is  given  in  teaspoonful 
doses  as  occasion  requires.  To  reduce  fever,  0.3  Gm.  (5 
grains)  of  quinine  or  phenacetine  may  be  given;  or  recourse 
may  be  had  to  the  tepid  or  cold  bath.  Calomel,  0.015  Gm. 
{\  grain)  three  times  a  day,  will  often  exert  a  good  influence 
on  the  course  of  the  disease. 

When  the  infection  has  passed  to  the  intestine,  calomel 
should  be  given,  to  be  followed  if  necessary  by  resorcinol 
with  salicylate  of  bismuth;  the  following  formula  has  been 
recommended : 

Gm.  or  Cc. 

I^ — Bismutbi  salicylatis 3.0  gr.  xlv 

Resorcinolis 2.0  gr.  xxx 

Glycerini 15.0  §ss 

Aquae 200.0  §vij 

Misce. 

Sig. — One  table.spoonful  every  three  hours. 

TOXIC  GASTRITIS 

Etiology. — Another  variety  of  severe  toxic  gastritis  is  that 
caused  by  cheixiical  poisons,  such  as  concentrated  mineral 
acids,  caustic  alkalies,  ammonia,  carbolic  acid,  oxalic  acid, 
alcohol,  phosphorus,  arsenic,  cyanide  of  potassium,  chlorate 
of  potash,  corrosive  sublimate,  lysol,  and  others. 


356  ACUTE  GASTRITIS 

Pathology. — The  most  marked  alterations  of  the  gastric 
mucous  membrane  are  produced  by  the  corrosive  poisons, 
acids  and  alkahes,  oxahc  acid,  carbohc  acid,  lysol,  and  cor- 
rosive subUmate.  At  first  the  wall  of  the  lower  end  of  the 
greater  curvature  not  far  from  the  pyloiiis,  or  the  posterior 
wall  of  the  stomach,  is  attacked  by  these  poisons,  the  loca- 
tion depending  on  the  position  of  the  patient  (that  is, 
whether  hdng  or  standing)  when  the  poisonous  substance  is 
ingested.  The  gastric  mucosa  is  hyperemic  and  greatly 
swollen,  subsequently  becoming  ulcerated;  the  ulcers  some- 
times penetrate  to  the  serous  coat,  or  even  to  complete 
perforation.  In  recovery  the  patient  may  have  pronounced 
distm'bance  of  the  motor  and  chemic  functions  of  the 
stomach;  there  is  apt  to  be  an  alteration  in  the  shape  and 
size  of  the  organ,  due  to  cicatrization.  Alcohol  and  phos- 
phorus do  not  produce  such  marked  lesions,  but  cause  an 
intense  irritation  and  inflammation  of  the  mucosa  together 
with  fatt}^  degeneration  of  the  glandular  epithelium. 

Symptoms. — The  symptoms  will  vary  according  to  the 
amount  of  poison  taken.  There  is  always  intense  burning 
pain  in  the  pharynx,  along  the  esophagus,  and  especially 
in  the  stomach.  Vomiting  soon  commences,  but  does  not 
bring  relief  to  the  patient.  The  vomited  matter  contains 
an  admixture  of  blood.  The  stomach  is  usually  distended, 
and  the  abdomen  exceedingly  sensitive  to  pressure.  Thirst 
is  always  a  feature.  In  cases  of  great  severity  the  pulse  is 
small,  the  lips  blue,  and  there  is  perspiration,  with  slight 
coma;  death  may  occur  in  collapse. 

Prognosis. — The  prognosis  in  such  cases  depends  upon  the 
quantity  of  poison  taken,  as  well  as  upon  the  condition  in 
which  the  patient  is  found.  Every  case  of  poisoning  should 
be  considered  serious,  and  recovery  a  matter  of  doubt. 

Treatment. — The  prime  requirement  is  to  remove  the  poison 
from  the  stomach  with  the  utmost  speed,  and  this  is  best 
accomplished  by  lavage.  It  is  sometimes  dangerous  to 
attempt  to  introduce  the  tube,  owing  to  the  possibility  of 
perforation.  Especially  is  this  likely  to  happen  in  poisoning 
by  acids  or  caustic  alkalies.     In  all  such  cases  the  best  mode 


PHLEGMONOUS  GASTRITIS  357 

of  treatment  is  to  effect  a  dilution  of  the  poison,  and  if 
possible  its  neutralization. 

In  the  treatment  of  poisoning  by  inorganic  acids,  alkalies 
are  indicated  to  neutralize  any  free  acid  in  the  pharynx, 
esophagus,  or  stomach.  Large  doses  of  magnesium  oxide, 
200  Gm.  (o viss)  in  four  portions  of  water;  well  diluted  caustic 
soda  in  a  mucilaginous  vehicle;  lime  water,  powdered  chalk, 
large  quantities  of  bicarbonate  of  soda,  are  suitable  antidotes. 
Care  should  be  exercised  in  the  employment  of  chalk  and 
bicarbonate  of  soda,  owing  to  the  generation  of  carbon 
dioxide  on  contact  with  the  acid.  In  poisonmg  by  organic 
acids,  saccharated  lime  may  be  given,  in  addition  to  the 
other  substances  mentioned,  for  the  purpose  of  converting 
the  acid  into  a  nearly  insoluble  lime  salt.  Thirty  grammes 
of  oxalic  acid  require  50  grammes  of  calcium  carbonate  or 
20  grammes  of  magnesia  for  saturation.  Cracked  ice  should 
be  administered,  and  ice  packs  applied  over  the  region  of 
the  stomach.     Morphine  may  be  given  for  the  relief  of  pain. 

In  cases  of  poisoning  by  alkalies,  such  acids  as  acetic  or 
citric  are  indicated  to  neutralize  the  caustic  effect  of  the 
poison.  Lysol  and  carbohc  acid  poisoning  call  for  thorough 
lavage  with  large  quantities  of  water  (2  or  3  liters);  large 
doses  of  sulphate  of  soda  are  useful;  lime  water  and  sac- 
charated lime  produce  the  comparatively  harmless  phenolate 
of  lime.  It  is  well  to  note,  too,  that  grain  alcohol  is  the 
nearest  approach  to  an  ideal  drug  we  have  for  neutralizing 
the  effect  of  carbolic  acid.  In  phosphorus  poisoning  the 
treatment  consists  in  long-continued  lavage  and  the  sub- 
sequent administration  of  half  a  teaspoonful  of  turpentine 
every  half-hour. 


PHLEGMONOUS  GASTRITIS 

This  is  among  the  rarest  of  gastric  diseases.  The  earliest 
description  of  the  disease  would  seem  to  be  in  a  communica- 
tion by  Veranadeus  in  1620.  In  the  latter  half  of  the  seven- 
teenth century  and  in  the  beginning  of  the  eighteenth  there 


358  ACUTE  GASTRITIS 

were  published  observations  on  phlegmonous  gastritis  b}^ 
Borel  (1656),  Sand  (1701),  Vorwaltner,  and  Bonet.  These 
observations  describe  the  circumscribed  form  only.  Andral 
(1839)  and  Cruveilhier  appear  to  have  been  the  first  to 
observe  the  diffuse  form  of  purulent  infiltration  of  the  gastric 
walls.  In  their  case  a  fortunate  accident  led  to  incisions 
into  the  stomach  walls,  which  revealed  a  diffuse  submucous 
suppurative  inflammation.  Since  1860  papers  on  both  the 
circumscribed  and  the  diffuse  forms  have  been  published  by 
Raynaud,  Auvray,  Leube,  Hun,  Glax,  Lowenstein,  Oser, 
Reinking,  Kelynack,  and,  finally,  a  very  admirable  mono- 
graph by  Leith,  of  Edinburgh,  in  1896.  Leith  was  able  to 
collect  only  51  positive  cases  of  the  diffuse  form  of  phleg- 
monous gastritis  in  the  entire  literature  of  the  subject, 
and  the  total  number  of  cases  of  both  diffuse  and  circum- 
scribed forms  is  given  as  85. 

The  disease  is  characterized  by  a  purulent  inflammation 
of  the  walls  of  the  stomach,  originating  in  the  submucous 
coat  and  gradually  extending  to  the  other  layers.  A  primary 
and  a  secondary  or  metastatic  form  of  the  disease  have  been 
distinguished.  The  condition  has  been  classified  also  as 
''diffuse  phlegmonous  gastritis,"  in  which  the  purulent 
infiltration  of  the  stomach  extends  over  a  large  area,  and 
'*  circumscribed,"  or  so-called  abscess  of  the  stomach.  It 
usually  runs  an  acute,  though  occasionally  a  subacute, 
course.  Only  about  90  cases  have  been  reported,  of  which 
number  the  majority  were  males.  The  metastatic  form  of 
the  disease  usually  originates  in  infectious  diseases — puer- 
peral fever  and  pyemia. 

Etiology. — The  cause  of  the  primary  affection  is  obscure. 
Alcoholism  has  been  suggested.  Traumatism,  dietetic  errors, 
exposure,  food  and  drug  poisoning,  puerperal  fever,  and 
carcinoma,  have  been  noted  as  contributory  factors;  they 
undoubtedly  lessen  the  power  of  resistance  so  that  the 
stomach  more  easily  becomes  a  nidus  for  i)y()geni('  liactcria. 
Kinnicutt^  reports  a  case  of  phlegmonous  gastritis  in  whicli 

'  I'liil;i'lcli)lii;i   I\I(ilic;il  .JoiiriKil,  NovciiiIut  17,   lUOO. 


PHLEGMONOUS  GASTRITIS  359 

bacteriologic  examination  revealed  the  universal  presence 
of  the  streptococcus;  it  was  most  abundant  in  the  connective 
tissue  of  the  submucosa  and  the  muscularis.  Two  cases 
were  reported  by  Robertson,^  in  which  the  direct  cause  was  a 
virulent  streptococcus  in  the  gastric  submucosa,  entering 
through  a  defect  in  the  mucosa  or  carried  by  the  blood  or 
Ij-mph  currents.  Many  associated  conditions  act  as  indirect 
causes,  and  of  these  gastric  ulcer  is  among  the  more  common. 
If  the  disease  be  due  to  bacterial  infection  of  the  submucous 
coat  through  some  small  abrasion  of  the  mucosa — which  is 
the  most  plausible  explanation — then  it  is  strictly  analogous 
to  cellulitis  of  the  subcutaneous  tissues  due  to  a  cutaneous 
defect  long  healed  before  the  cellulitis  is  observed.  This 
hypothesis  gives  a  clue  to  the  surgical  treatment,  to  be  dis- 
cussed later. 

The  secondary  form  of  this  disease,  apparently  due  to 
metastatic  infection,  may  originate  from  carcinoma  or  ulcer 
of  the  stomach.  In  one  case  gastritis  phlegmonosa  has  been 
observed  to  follow  an  enterostomy. 

Pathology. — The  essential  lesion  is  a  widespread  inflamma- 
tory change  in  the  submucous  coat,  which  is  greatly  thick- 
ened, usually  of  a  yellowish-white  color,  and  so  much  softened 
that  it  resembles  pus.  Microscopically  the  appearance  is 
that  of  fibrin  with  masses  of  leucocytes  entangled  in  it. 
This  change  is  nearly  always  more  marked  in  the  pyloric 
half  of  the  stomach,  a  fact  which  may  bear  some  relation 
to  the  anatomic  situation  of  the  oxyntic  or  acid-producing 
cells  of  the  gastric  mucosa.  The  muscular  coat  shows  vary- 
ing degrees  of  infection  and  degeneration  of  the  muscular 
elements.  The  serous  coat  is  sometimes  unaffected,  but  it 
may  show  leucocytic  infiltration,  especially  in  cases  where  a 
secondary  purulent  peritonitis  is  present.  The  mucosa  is 
in  many  instances  normal,  but  in  others  it  is  acutely  inflamed 
— raised  from  its  bed  in  ridges;  in  others  again  the  deeper 
layers  of  glandular  tubules  are  atrophied;  while  in  a  few  of 
the  recorded  cases  the  mucous  surfaces  have  been  pitted  with 

'  .Journal  of  the  American  Medical  Association,  December  28,  1907. 


360  ACUTE  GASTRITIS 

tiny  apertures,  giving  it  the  appearance  of  a  sieve,  through 
the  meshes  of  which  pus  could  be  squeezed  from  the  infil- 
trated submucous  layer.  The  duodenum  is  very  rarely 
altered,  and  then  only  the  mucosa  is  inflamed.  Of  secondary 
lesions,  peritonitis,  seropurulent  or  purulent,  is  the  com- 
monest, and  it  has  been  found  in  rather  more  than  half  the 
cases.  Pericarditis,  pleurisy,  and  abscess  of  the  liver  have 
also  been  observed. 

Symptoms  and  Com-se. — The  course  of  the  diffuse  form  of 
this  disease  is  atypical.  We  may  have  a  severe  acute 
gastritis,  with  high  fever,  sometimes  as  high  as  104°  F., 
violent  pains,  and  uncontrollable  vomiting,  the  abdomen 
greatly  distended,  the  pulse  feeble;  symptoms  of  collapse 
follow,  and  the  termination  is  usually  fatal. 

The  course  of  the  circumscribed  form  is  similar,  except 
that .  it  is  of  longer  duration,  extending  sometimes  over 
several  weeks.  Sometimes  a  tumor  can  be  felt  in  the  region 
of  the  stomach. 

The  prognosis  in  both  forms  of  phlegmonous  gastritis  is 
very  grave,  practically  hopeless.  Up  to  1896,  Leith,  who 
had  pubUshed  the  best  account  of  the  disease,  found  no 
authentic  cases  of  recovery;  and  from  the  records  of  cases 
since  that  date  it  appears  probable  that  the  few  recoveries 
noted  were  really  not  cases  of  primary  phlegmonous  gas- 
tritis, but  abscess  of  the  stomach. 

Treatment. — Since  the  diagnosis  is  never  positive,  the 
treatment  must  be  more  or  less  symptomatic.  Thei*e  is  no 
successful  treatment  of  this  disease.  The  stomach  should 
be  spared  as  much  as  possible.  Food  and  drink  should  be 
administered  per  rectum.  Ice  bags,  and  cocaine,  morphine, 
or  codeine  hypodermically,  are  indicated  for  the  relief  of 
pain.  High  temperatures  are  to  be  controlled  by  the  use 
of  antipyretic  drugs.  Stimulants  should  be  administered 
early  in  the  disease,  as  well  as  when  symptoms  of  collapse 
appear. 

This  disease  is  essentially  surgical.  Gastrostomy  or 
gastroenterostomy  is  suggested  by  Robson  and  Moynihan 
as  an  appropriate  method  of  dealing  with  the  lesion  surgi- 


PHLEGMONOUS  GASTRITIS  361 

cally,  but  it  is  difficult  to  see  how  a  surgical  operation  is 
going  to  cure  a  cellulitis  of  the  stomach  wall.  Probably 
incisions  down  to  the  submucous  coat,  with  free  exposure 
of  the  stomach  wall  and  packing  off  of  the  peritoneal  cavity 
with  gauze  left  in  position  for  several  days,  would  offer  the 
best  chance  of  recovery.  This  is  the  treatment  of  cellulitis 
in  subcutaneous  lesions,  and  if  it  could  be  effected  without 
infecting  the  general  peritoneal  cavity  it  seems  reasonable 
to  hope  that  satisfactory  results  might  be  obtained.  If  the 
nature  of  the  infecting  organism  can  be  learned,  the  appro- 
priate bacterial  vaccine  should  be  administered. 


CHAPTER    XVII 

CHRONIC    GASTRITIS:   SUBACID    GASTRITIS  —  ANACID 
GASTRITIS  —  ACHYLIA  GASTRICA 

CHRONIC  GASTRITIS  (CHRONIC  GASTRIC  CATARRH) 

Chronic  catarrhal  gastritis  is  a  chronic  inflammation  of 
the  gastric  mucous  membrane,  of  varying  degrees  of  inten- 
sity, presenting  symptoms  more  or  less  characteristic  of 
widely  different  forms  of  gastric  derangement.  At  one  time 
most  of  the  chronic  dyspepsias  were  designated  "chronic 
gastric  catarrh;"  but  the  epoch-making  work  of  Leube  has 
established  a  more  definite  classification.  Chronic  gastritis 
is  a  disease  which  requires  for  its  positive  diagnosis,  and  as 
a  rule  for  even  probable  diagnosis,  an  examination  of  the 
gastric  secretion. 

Etiology. — When  the  irritating  cause  of  acute  gastritis 
persists,  chronic  gastritis  is  the  natural  consequence;  but 
there  are  generally  other,  often  altogether  different,  etiologic 
factors.  Of  the  cases  of  chronic  gastritis  studied  b}'  Wilson 
Fox,i  pulmonary  tuberculosis  was  responsible  for  28  per 
cent.,  and  the  remainder  were  accompanied  by  cirrhosis  of 
the  liver,  chronic  lung  or  heart  disease,  chronic  Bright's 
disease,  or  other  chronic  ailment.  While  acute  gastric 
catarrh  is  a  frequent  concomitant  of  acute  infectious  disease, 
the  chronic  forms  depend  for  the  most  part  on  chronic  dis- 
turbance of  some  other  organ. 

Habershon'  classifies  chronic  gastric  catarrh  as  arising 
(1)  from  repeated  attacks  of  acute  gastric  catarrh  due  to  the 
nature  of  the  food  or  drink;  (2)  from  congestive  conditions 
related  especially  to  the  portal  system,  and  a  feature  of 
cardiac,  hepatic,  and  pulmonary  diseases,  the  stomach 
sharing  in  the  portal  engorgement  or  in  a  general  systemic 

»  IlMhcnslion,  Disi'UK's  of  tin-  Sloin.icli,  l'.)l().  '  Ibid. 


PATHOLOGY  303 

congestion;  (3)  from  chronic  diseases,  such  as  tuberculous 
peritonitis,  where  the  inflammatory  condition  is  an  exten- 
sion  from   neighboring  organs. 

Under  the  first  subdivision  must  be  placed  alcoholic  excess 
as  the  most  frequent  etiologic  factor.  Those  who  habitually 
indulge  in  alcoholic  beverages  to  excess  are  disposed  to  an 
irregular  mode  of  life  which  leads  to  digestive  disturbances. 
Along  with  the  abuse  of  alcohol  should  be  placed  the  exces- 
sive use  of  tobacco  and  the  prolonged  use  of  tonics  and  pur- 
gatives. Food  poisoning  is  another  cause ;  likewise  errors  of 
diet — excessive  alimentation,  the  habit  of  eating  at  irregular 
intervals,  the  quick-lunch  counter,  insufficient  mastication 
of  food,  and  the  too  frequent  use  of  ice  water  or  of  tea  and 
coffee.  ''In  this  country,"  says  Einhorn,  ''ice  w^ater  and 
fast  eating  are  the  two  principal  causes  of  'American 
dyspepsia.'" 

In  class  2,  local  mechanical  influences,  such  as  portal 
congestion,  may  result  in  obstruction  of  the  outflow  of 
venous  blood  from  the  stomach  to  the  right  heart.  Thus 
chronic  gastric  catarrh  occurs  as  a  secondary  process  in  the 
course  of  chronic  affections  of  the  liver,  heart,  and  lungs. 
The  explanation  of  the  peculiar  tendency  of  such  chronic 
affections  as  gout,  chronic  rheumatism,  tuberculosis,  Bright's 
disease,  diabetes,  anemia,  chlorosis,  syphilis,  and  chronic 
forms  of  skin  disease  to  produce  chronic  gastric  catarrh, 
lies  in  the  obstruction  offered  to  the  passage  of  the  blood 
through  the  hepatic  and  cardiopulmonary  circulation. 
Especially  is  this  true  in  tuberculosis,  chlorosis,  and  anemia. 
In  gout,  chronic  Bright's  disease,  and  syphilis,  the  chi^onic 
gastric  catarrh  is  due  more  to  the  action  of  chemicovital 
irritants  in  the  blood. 

Gastric  carcinoma  also  has  a  place  in  the  etiology  of 
chronic  gastric  catarrh. 

Pathology. — In  chronic  gastritis  it  is  not  the  superficial 
epithelium  alone  that  is  affected,  but  the  inflammatory 
process  extends  to  the  glandular  epithelium  and  to  the 
interstitial  tissue.  In  the  initial  stage  of  simple  chronic 
gastritis  the  mucous  membi^ane  is  pale  gra}^  in  color  and 


364  CHRONIC  GASTRITIS 

covered  with  closely  adherent  tenacious  mucus.  The  veins 
are  enlarged,  and  patches  of  ecch3^mosis  are  sometimes  seen. 
The  glands  are  subject  to  parenchjanatous  and  interstitial 
inflammation,  presenting  a  microscopic  picture  of  erosion, 
cloudy  swelhng,  or  atrophy,  depending  upon  the  stage  of 
the  disease.  It  is  not  possible  to  chfferentiate  between  the 
principal  and  the  parietal  cells,  owing  to  the  fact  that  the 
tubes  have  lost  their  regular  form  and  instead  we  have, 
as  Ewald  expresses  it,  "atypical  branching  hke  the  fingers 
of  a  glove."  There  is  an  infiltration  of  round  cells  and 
proliferation  of  connective  tissue,  which  exert  pressure  on  the 
glands,  thus  inhibiting  their  normal  function.  As  these 
pathologic  changes  become  more  marked  the  secretion 
becomes  progressively  less  until  the  atrophic  stage  is  reached, 
when  we  have  an  entire  absence  of  secretion.  ^Meanwhile 
a  mucoid  degeneration  of  the  cells  lining  the  tubules  takes 
place  and  may  even  extend  to  the  fundus  of  the  glands. 
In  the  Ughter  forms  of  chronic  gastritis  the  submucosa  and 
the  interglandular  connective  tissue  are  infiltrated  bj^  inflam- 
matorj^  products.  When  the  disease  has  progressed  to 
greater  length  and  has  become  more  severe  the  infiltration 
of  the  intercellular  tissues  is  more  marked.  There  is  a 
prohferation  of  connective  tissue,  so  that,  toward  the  pylorus 
in  particular,  we  have  a  rough,  wrinkled,  mammillated  sur- 
face, the  etat  mamelonne  of  the  French,  a  condition  which  is 
sometimes  so  prominent  that  it  has  been  described  as 
gastritis  polyposa.  The  pathologic  changes  may  even  lead 
to  stenosis  of  the  pylorus. 

The  inflammation  in  the  more  aggravated  cases  may  pass 
to  the  muscular  layers,  causing  partial  destruction,  to  be 
replaced  by  connective-tissue  fibres.  Belonging  to  this 
form  of  the  disease  is  sclerotic  gastritis  (cirrhosis  ventriculi), 
in  which  the  walls  of  the  stomach  undergo  a  connective- 
tissue  metamorphosis,  sometimes  to  such  an  extent  that  the 
stomach  is  greatly  reduced  in  size.  Fenwick,  Ewald,  and 
other  writers  have  noted  cases  of  extreme  atrophy  of  the 
gastric  mucous  membrane,  and  the  fact  is  now  recognized 
that  there  may  be  such  destruction  of  the  glandular  elements 


SYMPTOMS  365 

by  a  progressive  growth  of  interstitial  tissue  that  ultimately 
scarcely  a  trace  of  secreting  tissue  remains.  Osier  describes 
a  case  in  which  the  greater  portion  of  the  lining  membrane 
of  the  stomach  was  converted  into  a  perfectly  smooth 
cuticular  structure,  showing  no  trace  whatever  of  glandular 
elements,  with  enormous  hypertrophy  of  the  muscularis 
mucosa,  and  here  and  there  formation  of  cysts. 

Symptoms. — The  local  symptoms  have  a  strong  resemblance 
to  those  of  other  forms  of  gastric  disturbance.  The  disease, 
as  a  rule,  develops  very  slowly,  and,  as  in  the  case  of  most 
chronic  diseases,  changes  from  time  to  time.  The  appetite 
varies;  sometimes  it  is  very  poor,  and  sometimes  it  is  good. 
Patients  usually  complain  of  a  disagreeable  taste,  which  they 
describe  as  salty  or  pappy,  or  at  times  sour;  of  thirst, 
salivation,  and  eructation  of  gas  or  food  remnants,  which 
may  be  sour,  rancid,  or  tasteless.  The  breath  is  often  fetid. 
Nausea  is  rather  common.  Pressure  and  fulness  are  experi- 
enced after  eating.  Patients  complain  of  palpitation  of  the 
heart.  Belching  (which  is  very  annoying  to  the  patient) 
relieves  both  the  pressure  and  the  consequent  palpitation. 
Irregular  stools,  constipation,  and  diarrhea  are  commonly 
met  with  in  chronic  catarrhal  gastritis.  Patients  suffer  from 
headaches,  vertigo,  and  disturbed  sleep.  There  are  vaso- 
motor disturbances,  with  sensations  of  coldness  of  the  ex- 
tremities. 

Objective  Symptoms. — The  subjects  of  chronic  gastric 
catarrh  generally  appear  to  be  well  nourished.  Some,  how- 
ever, are  seen  to  have  lost  weight  and  look  emaciated. 

The  tongue  is  usually  coated  gray  or  yellowish-gray; 
still,  in  many  cases  of  well-marked  chronic  gastritis  the 
tongue  is  clean.  There  may  be  no  offensive  odor  in  the 
mouth,  or  if  there  is  any  it  may  be  due  to  carious  teeth  or 
some  pathologic  condition  of  the  nose  or  throat. 

The  gastric  region  often  appears  bloated.  Palpation 
reveals  slight  sensitiveness  of  the  entire  area  over  the 
stomach.  The  pylorus  may  be  palpated  when  thickened 
by  muscular  hypertrophy. 


366  CHRONIC  GASTRITIS 

Diagnosis. — It  is  seen  that  there  are  no  symptoms,  either 
subjective  or  objective,  which  are  pathognomonic  of  the 
disease.  An  approximate  diagnosis  can  be  estabhshed  only 
by  an  examination  of  the  secretory  and  motor  functions  of 
the  stomach  and  the  anamnesis.  The  presence  of  mucus 
in  the  stomach  must  be  ascertained  before  we  are  justified 
in  making  a  diagnosis  of  chronic  gastric  catarrh.  From  the 
stomach  under  normal  conditions  it  is  possible  to  obtain 
only  a  few  isolated  flakes  of  mucus,  even  after  most  thorough 
lavage.  In  chronic  gastritis  mucus  is  usually  present  in 
marked  quantities,  and  is  found  mixed  with  food  remnants. 
Mucus  which  has  got  into  the  stomach  from  the  nose, 
pharynx,  or  trachea  is  found  upon  the  surface  of  the  liquid  or 
food  removed  from  the  stomach  with  the  stomach  tube. 

The  acid  secretion  in  chronic  gastric  catarrh  varies. 
In  the  initial  stages  the  percentage  of  free  hydrochloric  acid 
is  often  found  to  be  normal.  Sometimes  there  is  hyper- 
aciditA^,  a  condition  which  corresponds  to  the  acid  gastritis 
described  by  Boas.  As  the  disease  progresses,  the  secretory 
function  becomes  impaired,  with  a  resultant  decline  from 
the  normal  amount  of  free  hydrochloric  acid.  In  the  more 
protracted  cases  there  is  no  free  hydrochloric  acid  at  all, 
and  the  other  constituents  of  the  gastric  secretion  are  very 
much  diminished  in  quantity.  The  diminution  of  free  hydro- 
chloric acid  is  in  direct  proportion  to  the  intensity  of  the 
disease  process;  when  very  marked,  the  condition  is  desig- 
nated subacid  gastritis.  Further  progress  of  the  disease 
converts  the  subaciditj'  into  anacidity,  a  condition  in  which 
the  formation  of  pepsin  begins  to  fail.  This  pathologic  state 
is  known  as  anacid  gastritis.  The  symptoms  of  this  form 
of  chronic  catarrhal  gastritis  may  be  ameliorated  by  appro- 
priate treatment  so  long  as  the  alterations  in  the  gastric 
mucosa  have  not  become  so  marked  as  to  prevent  the 
possibility  of  the  secretion  of  })oth  hydrochloric  acid  and 
pepsin. 

The  final  stage  of  the  disease  is  that  of  chronic  anacid 
gastritis  with  atrophy  of  the  secreting  glands.  The  patho- 
logic changes  in  the  gastric  mucosa  are  so  great  as  to  ]ii-ochido 


DIAGNOSIS  3(37 

the  possibility  of  restitution  of  the  secretory  functions  of 
the  stomach.  When  this  stage  is  reached,  rennin  as  well 
as  pepsin  and  hydrochloric  acid  are  absent.  Organic  acids 
are,  as  a  rule,  not  present  in  chronic  gastritis,  but  are  found 
only  when  stagnation  is  a  complication.  The  production 
of  mucus  may  become  very  large  in  the  atrophic  stage  of 
the  disease. 

The  term  ''subacidity"  is  applied  to  cases  in  which  free 
hydrochloric  acid  is  decreased  and  the  total  acidity  is  less 
than  40  degrees.  The  secretion  of  the  ferments  may  be 
normal.  Subacidity  may  be  found  as  a  secondary  affection 
in  the  course  of  chronic  diseases  of  the  stomach,  such  as 
carcinoma  and  chronic  gastritis.  It  may  likewise  follow 
anemia,  phthisis,  acute  febrile  diseases,  and  cardiorenal 
diseases. 

It  is  a  question  whether  gastric  anacidity  may  exist  as  an 
independent  primary  affection,  or  whether  it  is  to  be  always 
regarded  as  a  later  stage  of  chronic  gastritis  characterized 
by  atrophy  of  the  gastric  mucosa.  The  possibility  of  gastric 
anacidity  as  a  primary  affection  would  seem  to  be  assured 
by  cases  of  purely  nervous  or  functional  disturbance,  or 
by  cases  in  which  there  is  an  inherent  deficiency  in  the 
secretory  function  of  the  stomach.  The  examination  of 
stomach  contents  in  such  cases  reveals  an  unaltered  condi- 
tion of  the  test  meal.  The  particles  of  bread  are  larger 
or  smaller,  depending  upon  the  thoroughness  of  mastica- 
tion, and  have  the  appearance  of  being  merely  moistened  or 
softened  by  the  water.  Mucus  is  not  present.  The  total 
acidity  is  extremely  low — 4  to  6  degrees  and  frequently  zero. 
The  reaction  of  the  stomach  contents  is  very  slightly  acid, 
sometimes  amphoteric  on  account  of  the  presence  of  phos- 
phates in  the  food.  In  the  majority  of  cases  there  is  a 
slight  secretion  of  pepsin. 

Very  often  individuals  with  anacidity  or  subacidity  feel 
perfectly  well,  or  at  least  experience  no  great  discomfort. 
They  appear  well  nourished.  Cases  have  been  observed  in 
which  gastric  anacidity  has  persisted  for  periods  of  twelve 
to  fifteen  years.     In  this  class  of  cases  the  power  of  the 


368  CHRONIC  GASTRITIS 

stomach  to  digest  protein  is  entirely  absent,  so  that  the  small 
intestine  receives  all  the  protein  in  an  unchanged  condition. 

The  digestion  of  carbohydrates  is  impaired  to  a  certain 
extent,  owing  to  the  fact  that  the  cellulose  covering  of  the 
starch  granule  is  not  dissolved.  These  obstacles  to  com- 
plete digestion  tend,  in  time,  to  have  a  harmful  effect  upon 
the  small  intestine. 

The  motor  activity  of  the  stomach  is  usually  normal. 
Stagnation  is  found  only  in  those  cases  in  which  there  is 
hypertrophy  of  the  muscular  layers  of  the  stomach  near 
the  pylorus.  Absorption  of  many  food  substances  is 
retarded,  though  Einhorn  maintains  that  he  has  not  been 
able  to  detect  any  marked  departure  from  the  normal. 

Prognosis. — The  prognosis  of  chronic  gastritis  is  favorable; 
the  disease  is  amenable  to  treatment,  so  that  a  complete  cure 
or  material  improvement  may  be  anticipated.  Relapses  are, 
however,  likely  to  occur. 


ACHYLIA  GASTRICA 

''Achylia  gastrica"  is  a  term  introduced  into  medical 
literature  by  Einhorn  to  denote  absence  of  gastric  secretion. 
The  stomach  contents  contain  no  free  or  combined  hydro- 
chloric acid;  the  ferments  are  likewise  absent  or  greatly 
reduced  in  amount.  Achylia  is  a  sign  of  disturbed  function 
of  the  stomach  which  may  accompany  such  diseases  as 
cancer,  severe  anemia,  or  chronic  gastric  catarrh.  It  may 
also  occur  as  a  purely  functional  disturbance  wholly  apart 
from  primary  organic  disease  of  the  stomach  or  other  organs. 

Etiology. — -According  to  White,  ^  the  history  of  achjdia  is 
closely  associated  with  that  of  atrophy  of  the  gastric  mucosa, 
and  the  discovery  of  a  lack  of  gastric  secretion  in  cancer 
and  in  gastric  atrophy  led  to  the  false  opinion  that  if  no 
hydrochloric  acid  or  ferments  were  found  the  diagnosis  of 
cancer  or  atrophy  was  justified.  The  association  of  achylia 
with  severe  and  fatal  disease  led  also  to  the  false  belief  that 

'  Boston  Medical  and  Surgical  Journal,  November  8,  1906. 


ACHY  LI  A   CAST  RICA  369 

it  was  necessarih^  a  severe  condition  leading  in  a  short  time 
to  death.  We  know  now  that  an  absolute  and  permanent 
lack  of  gastric  secretion  is  compatible  with  health  and  well- 
being,  and  that  the  gastric  secretion  can  be  compensated 
by  intestinal  digestion.  In  short,  we  can  make  a  sharp 
distinction  clinically  between  (a)  secondary  achylia  associated 
with  cancer,  severe  anemia,  or  atrophy  of  the  gastric  mucosa, 
and  (b)  simple  achylia  without  atrophy,  which  is  a  benign 
condition. 

The  etiology  of  achylia  gastrica  is  often  obscure.  Inherent 
weakness,  probably  hereditary,  of  the  secretory  processes, 
plaj^s  an  important  part  in  the  causation  of  the  disease. 
The  condition  is  frequently  found  in  neurasthenia.  It  has 
been  shown  by  animal  experimentation  that  section  of 
those  branches  of  the  pneumogastric  nerve  which  supply 
the  stomach  is  followed  by  inhibition  of  secretion.  Inter- 
ference with  the  function  of  the  pneumogastric  nerve  may 
account  for  those  rare  cases  in  which  in  the  same  person  we 
have  hyperacidity,  subacidity,  and  achylia.  Achyha  gas- 
trica may  occur  at  any  age;  the  youngest  patient  on  record 
was  nine  years  old. 

White^  further  states:  ''The  etiology  of  this  simple 
achylia  gastrica  is  an  interesting  biological  problem  with  a 
practical  side.  A  well-known  and  important  function  is 
absent  without  definite  cause  or  apparent  results.  The  latter 
may  be  explained  by  compensation.  The  intestinal  diges- 
tion is  so  powerful  that  gastric  digestion  seems  almost 
superfluous.  It  is  not,  however,  simply  an  anomaly,  the 
disappearance  of  a  function  which  is  unnecessary  for  the 
organism  (cf.  Darwin);  it  is  a  diseased  condition.  The 
individual  with  achylia  is  worse  off  than  his  mates — he  is 
in  a  state  of  unstable  equilibrium,  and  bowel  trouble  may 
be  a  real  danger.  The  fact  that  achylia  patients  are  neuras- 
thenic is  not  a  sufficient  reason  to  consider  this  the  cause. 
We  find  neurasthenia  without  loss  of  secretion,  and  loss  of 
secretion  without  neurasthenia. 

''Alartius  considers  it  a  primary  weakness  of  secretion 

1  Loc.  cit. 
24 


370  CHRONIC  GASTRITIS 

which  is  either  congenital  or  develops  on  the  basis  of  a 
predisposition.  The  hereditary  element  is  interesting. 
Cases  have  been  reported  in  a  mother  and  daughter,  and  in 
two  brothers.  An  anatomic  basis  for  the  condition  has 
been  suggested.  Hemmeter  cites  10  cases  of  achylia  (which 
do  not  include  cases  of  cancer  or  chronic  gastric  catarrh), 
in  9  of  which  fragments  of  the  mucosa  obtained  through 
the  tube  were  examined.  These  all  showed  signs  of  granular 
gastritis  and  atrophy.  Hemmeter  questions  whether  the 
condition  is  ever  a  neurosis.  The  changes  in  the  mucosa, 
however,  seem  far  too-  shght  to  explain  the  striking  change 
in  function  (compare  the  conditions  in  gastric  cancer, 
where  the  secondary  change  in  the  mucosa  leads  to  achylia 
only  when  it  has  advanced  to  atrophy),  and  the  granular 
gastritis  may  be  the  result,  not  the  cause,  of  the  achyha. 
It  is  not  satisfactory  to  use  the  evidence  from  fragments 
of  mucosa  obtamed  through  the  stomach  tube  to  settle  a 
question  of  secretion,  which  is  the  expression  of  the  function 
of  the  whole  stomach.  In  addition,  we  have  seen  one  case, 
similar  to  those  reported  by  Einhorn  and  others,  of  recovery 
of  gastric  secretion  after  a  long  period  of  achylia,  showing 
that  achylia  may  exist  when  the  glands  of  the  stomach  have 
not  been  totally  destroyed.  In  such  cases  the  condition  is 
probably  due  to  nervous  influences,  with  partial  atrophj', 
but  no  autopsies  have  been  reported,  and  the  atrophy  can 
only  be  conjectured,  not  proved.  In  short,  cases  of  achylia 
may  be  divided  into  two  groups:  first,  the  severe  and  strik- 
ing cases,  which  were  earliest  reported,  in  which  there  is 
unquestioned  atrophy  of  the  mucous  membrane  (either 
idiopathic  or  secondary  to  some  serious  condition,  such  as 
cancer  or  pernicious  anemia);  and  second,  the  group  of 
cases,  which  are  by  no  means  rare,  in  which  achylia  occurs 
in  neurasthenic,  weak  persons,  those  of  middle  life  and 
beyond,  where  the  condition  is  simply  that  of  a  weak 
stomach  with  feeble  secretion." 

Pathology. — The  mucous  membrane  has  been  for  the  most 
part  normal  in  many  cases  examined,  while  in  some  cases 
it  was  found  to  be  atrophied. 


TREATMENT  OF  GASTRITIS  AND  ACHY  LI  A  GASTRIC  A      371 

Symptoms.— The  clinical  symptoms  of  achylia  gastrica 
resemble  those  of  chronic  gastric  catarrh;  there  are  loss  of 
appetite,  nausea,  vomiting,  slight  pains,  and  eructations. 
In  many  instances  the  patient  feels  well,  and  the  existence 
of  the  disease  is  discovered  by  accident. 

Achylia  gastrica  may  be  unmarked  by  the  presence  of 
any  distressing  symptoms,  or,  if  such  symptoms  are  present, 
they  may  be  wholly  non-characteristic  of  the  pathologic 
condition.  The  symptoms  usually  consist  of  diminished 
desire  for  food,  pressure,  fulness  in  the  stomach,  discomfort 
after  eating,  or  eructations.  There  is  often  an  acceleration 
of  the  motility  of  the  stomach,  said  to  be  due  to  the  absence 
of  hydrochloric  acid;  hydrochloric  acid,  if  present,  would 
cause  a  periodic  closure  of  the  pylorus.  The  food  passes 
with  more  than  normal  rapidity  into  the  small  intestine. 
Patients  with  achylia  gastrica  may  maintain  a  fair  state  of 
health  so  long  as  the  small  intestine  is  functionally  active. 
Should  intestinal  digestion,  however,  become  impaired,  the 
result  would  be  a  diarrhea  (gastrogenic  diarrhea),  causing 
marked  emaciation  or  even  endangering  life. 

Cases  described  as  secondary  achylia  are  sometimes  found 
accompanying  such  diseases  as  diabetes,  tuberculosis,  cir- 
rhosis of  the  liver,  cardiac  disease,  and  arteriosclerosis  of  the 
abdominal  vessels.  Then  there  is  that  form  of  achylia  which 
accompanies  grave  cases  of  anemia,  pernicious  anemia,  and 
the  anemia  due  to  the  Bothriocephalus  latus.  The  relation 
between  achylia  and  these  pathologic  conditions  is  not  clear. 


TREATMENT   OF   CHRONIC   GASTRITIS   AND   ACHYLIA 
GASTRICA 

Chronic  gastritis  and  achylia  gastrica  have  as  a  common 
manifestation  a  perversion  of  gastric  secretion  which  consists 
for  the  most  part  of  a  diminution  in  activity  of  the  secretory 
function.  This  common  functional  derangement  renders  it 
advantageous  to  discuss  the  treatment  of  the  two  condi- 
tions together. 


372  CHRONIC  GASTRITIS 

Since  repeated  attacks  of  simple  acute  gastritis  may  result 
in  the  development  of  chronic  gastritis,  it  is  important  that 
the  patient  should  avoid  any  excesses  or  practices  which 
predispose  to  the  attacks.  He  should  masticate  his  food 
thoroughly,  and  should  avoid  overindulgence  in  alcohol, 
tobacco,  extremes  of  temperature  in  food,  as  well  as  highly 
spiced  articles  of  diet.  The  mouth  and  teeth  should  be 
kept  in  good  condition.  Slow  eating  followed  by  rest, 
exercise  in  the  open  air,  sleeping  with  the  windows  open, 
cold  salt-water  sponging  at  night  followed  by  a  brisk  rub, 
are  excellent  by  way  of  prophylaxis. 

Diet. — The  regulation  of  diet  is  perhaps  the  most  impor- 
tant factor  in  the  treatment  of  conditions  marked  by  sub- 
acidity  or  anacidity,  since  a  restoration  of  the  secretory 
functions  of  the  stomach  to  normal  is  sometimes  impossible. 

The  power  to  digest  protein  is  either  greatly  impaired 
or  altogether  absent.  The  digestion  of  carbohydrates  in  the 
stomach  would  be  satisfactory  were  it  not  for  the  vegetable 
protein  enveloping  the  starch  granule;  but  proteolysis 
must  be  carried  on  for  the  most  part  or  altogether  by  the 
small  intestine.  The  unusual  demand  made  upon  the  small 
intestine  ^\dll  sooner  or  later  result  in  impairment  of  its 
function.  It  is  seen,  then,  that  rational  treatment  must 
be  directed  toward  protecting  the  stomach  and  small  intes- 
tine. A  diet  rich  in  carbohydrate,  with  a  minimum  of 
protein,  is  indicated.  The  individual  tastes  of  patients 
should  not,  however,  be  ignored.  Some  patients  object 
to  a  monotonous  diet.  To  avoid  aversion  certain  con- 
cessions may  be  granted,  but  all  food  should  be  tender  and 
susceptible  of  thorough  mastication.  In  chronic  gastritis 
spiced  foods  may  be  permitted,  owing  to  their  stimulating 
influence  upon  the  appetite.  In  spite  of  ai)parent  restric- 
tion, the  choice  of  appropriate  articles  of  diet  may  be  suffi- 
ciently varied.  The  patient  may  be  allowed  all  the  tender 
meats,  such  as  fowl,  brain,  or  lean  fish.  Meat  should  be 
thoroughly  roasted  or  boiled;  raw,  pickled,  or  smoked  meats 
and  salted  fish  should  be  avoided.  The  daily  quantity  of 
meat  should  not  exceed  150  grammes,  and  in  sovore  cases 


THE  AT  ME  XT  OF  GASTRITIS   AND  ACHY  LI  A   GASTRIC  A      373 

not  more  than  100  grammes  should  be  taken  during  the  day. 
]\Ieat  may  be  replaced  occasionally  by  eggs,  soft  boiled  or 
in  the  form  of  egg  soups  or  light  omelets.  Milk  is,  as  a  rule, 
well  borne,  and  is  strongly  recommended;  it  may  be  em- 
ployed as  a  vehicle  for  somatose,  sanatogen,  or  plasmon, 
and  its  digestibility  may  be  further  increased  by  the  addition 
of  pegnin.  Fats  in  the  form  of  butter  and  cream  are  per- 
mitted this  class  of  patients.  Vegetables  may  be  prescribed 
in  the  form  of  thick  strained  soups  (rice,  tapioca,  sago,  peas, 
lentils);  and  mashed  potatoes  in  moderate  quantities  are 
permissible.  Biscuits,  zwieback,  toast,  stale  white  bread, 
which  can  be  broken  up  fine  in  the  mouth  or  softened  by 
being  dipped  into  fluids,  are  indicated.  Such  condiments  as 
salt,  pepper,  and  mustard  have  a  stimulating  effect  on  the 
appetite,  though  thej^  will  not  bring  back  the  gastric  secre- 
tion. The  meat  extracts  have  a  similar  action.  Pure  water 
or  weak  lemonade  is  the  most  satisfactory  beverage  for 
allaying  the  thirst,  and  is  best  taken  during  the  intervals 
between  meals.     Carbonated  waters  are  also  good. 

Gastric  motility  is  usually  normal  in  chronic  gastritis. 
When,  however,  there  is  any  disturbance  in  motility,  it 
may  be  overcome  by  making  the  meals  small  and  frequent, 
thus  avoiding  the  overdistention  of  the  stomach  which 
large  meals  are  apt  to  induce.  The  quantity  of  liquids 
should  be  restricted,  inasmuch  as  they  tend  to  produce 
hyperdistention. 

Ewald's  diet  for  chronic  gastritis  is  as  follows: 

8  A.M.     150  to  200  Gm.    tea,  with  75  to  100  Gm.  stale  white  bread, 
toast,  or  zwaeback. 
10  A.M.     50  Gm.  white  bread,  10  Gm.  butter,  50  Gm.  cold  meat  or  ham, 
one-third  hter  of  milk. 
2  P.M.     150  to  200  Gm.  water,  milk,  or  bouillon  of  the  white  meats,  100 
to  125  Gm.  meat  or  fish,  80  to  100  Gm.  vegetables,  80  Gm. 
compot. 
4  to  5  P.M.     One-fourth  to  one-third  liter  of  warm  milk  (occasionally  mixed 
with  cocoa  or  coffee) . 
7  to  8  P.M.   200  Gm.  soup  or  pap,  50  Gm.  white  bread,  10  Gm.  butter. 
Occasionally  at  10  p.m.      50  Gm.  wheaten  bread  (biscuits   or  zwieback), 
one  cup  of  tea. 


374  CHRONIC  GASTRITIS 

Diet  for  First  Week  of  Treatment  (Einhorn) 

Calories. 

8.00  a.m.      Two  eggs 160 

French  white  bread,  60  Gm.  (5'.]) 156 

Butter,  15  Gm.  (gss) 107 

One  cup  of  tea  (100  Gm.  tea,  150  Gm.  milk)      ...      101 
Sugar,  10  Gm.  (oiiss) 40 

10.30  a.m.      Koumiss,  matzoon,  or  milk,  250  Gm ■  168 

Crackers,  30  Gm.  (§j) 107 

Butter,  20  Gm.  (3  v) 163 

12.30  p.m.      Two  ounces  tenderloin  steak  or  white  meat  of  chicken  72 

Mashed  potatoes,  or  thick  rice,  100  Gm.  (giij)  .      .      .  127 

White  bread,  60  Gm.  (Bij)       .      . 153 

Butter,  15  Gm.  (5ss) 107 

One  cup  of  cocoa,  200  Gm.  (§vij) 101 

3.30  p.m.      The  same  as  at  10.30  a. m 438 

6.30  p.m.      Farina,  hominj^,  or  rice  boiled  in  milk,  one  plateful, 

250  Gm.  (Sviij) 440 

Two  scrambled  eggs 160 

Bread,  60  Gm.  (§ij) 156 

Butter,  15  Gm.  (5ss) 107 

2863 

When  the  patient  has  been  kept  on  this  diet  for  a  week 
or  two,  it  should  be  gradually  changed  to  one  suitable  for 
lighter  forms  of  chronic  gastritis.  The  distribution  of  meals 
should  conform  as  nearly  as  possible  to  the  custom  of  the 
community  in  which  the  patient  lives.  According  to  Ein- 
horn: "All  foods  derived  from  the  vegetable  kingdom 
should  be  given  in  large  quantities,  while  the  amount  of 
meat  should  be  limited.  In  order  to  permit  the  patient  to 
have  a  greater  variety  of  food,  it  is  best  not  to  point  out  a 
few  articles  he  should  eat,  but  to  mention  only  those  he 
should  avoid.  Forbid  meat  with  very  tough  fibres,  meat 
from  too  old  animals,  too  fresh  meat  (right  after  slaughter- 
ing) ,  and  meat  that  contains  too  much  fat  (like  pork) ;  forbid 
sausages,  lobster,  salmon,  chicken  salad,  mayonnaise,  cucum- 
bers, pickles,  cabbage,  strong  alcoholic  drinks  (like  liquors)." 


TREATMENT  OF  GASTRITIS  AND  . 

ACHY  LI  A 

GASTRICA      3 

DiETAR-V 

Li.sT  FOR  Cases  of  Chronic  Gastric  Catarrh  (Wegele) 

(Grave 

form,  with  destruction  of  the  Gastric  Glands 
Membrane) 

Protein. 

^  in  the  Mucous 

Carbo- 
Fats.          hydrates 

Morning. 

150  Gm.  hygiama 

4.0 

1.5 

10.0 

50  Gm.  zwieback 

6.5 

1.5 

42.0 

10  Gm.  butter      .... 

0.7 

8.2 

0.06 

10  Gm.  plasmon  .... 

7.4 

8.1 

0.2 

Forenoon. 

200  Gm.  oatmeal   .... 

3.0 

6.0 

17.0 

10  Gm.  aleuronat 

9.1 

0.07 

10.0 

50  Gm.  zwieback 

6.5 

1.5 

42.0 

10  Gm.  butter      .... 

0.07 

8.2 

0.06 

Noon. 

100  Gm.  beefsteak  (chopped) 

30.8 

1.5 

100  Gm.  rice 

2.0 

7.0 

8.0 

100  Gm.  pudding  .... 

9.0 

16.0 

13.0 

100  Gm.  apple  sauce   . 

0.2 

8.0 

Afternoon. 

150  Gm.  cocoa        .      .      .      ; 

4.0 

1.5 

10.0 

50  Gm.  zwieback 

6.5 

1.5 

42.0 

10  Gm.  butter      .... 

0.07 

8.2 

0.06 

10  Gm.  somatose. 

8.1 

Evening. 

200  Gm.  pap 

3.0 

6.0 

17.0 

10  Gm.  plasmon  .... 

2.3 

1.4 

3.8 

100  Gm.  macaroni 

5.5 

14.3 

60.3 

100  Gm.  apple  sauce  . 

10.2 

8.0 

118.94 

92.47 

291.48 

Calories,  about .... 

440 

800 

1200 

Total  combustive  value,  2440 

calories. 

Diet  Free  from  Meat  in  Chroni 

c  Gastritis 

OR   ACHYLIA 

Protein. 

Fats. 

Carbo- 
hydrates. 

Morning. 

200  Gm.  milk  cocoa     . 

7.2 

8.0 

10.0 

100  Gm.  zwieback 

9.0 

1.0 

60.0 

30  Gm.  butter      .... 

0.2 

25.0 

Lunch. 

200  Gm.  gruel        .... 
20  Gm.  butter      .... 

3.0 

6.0 
17.0 

17.0 

50  Gm.  zwieback 

4.5 

0.5 

30.0 

Noon. 

200  Gm.  rice 

0.4 

10.0 

16.0 

200  Gm.  pudding  .... 

13.5 

24.2 

46.0 

100  Gm.  apple  sauce   . 

0.2 

8.0 

Afternoon. 

200  Gm.  milk  cocoa     . 

7.0 

1.0 

10.0 

(Tea) 

100  Gm.  zwieback 

9.0 

1.0 

60.0 

30  Gm.  butter      .... 

0.2 

25.0 

Evening. 

200  Gm.  oatmeal  .... 

3.0 

6.0 

17.0 

(Supper) 

200  Gm.  water  noodles 

15.0 

0.6 

100.0 

100  Gm.  plum  jam 

0.2 

10.0 

50  Gm.  zwieback       .      .      .      . 

4.5 

0.5 

30.0 

20  Gm.  butter 

76.9 

17.0 

142.8 

414.0 

Calories 

300 

1400 

1600 

375 


Total  combustive  value,  3300^caiories. 


376  CHRONIC  GASTRITIS 

Fleiner  recommends  in  severe  cases  of  anacidity  300  to 
800  grammes  of  oatmeal  in  the  morning,  after  which  the 
patient  should  assume  the  recumbent  position  for  one  hour. 

Two  and  one-half  to  three  hours  later  the  patient  should 
take  300  to  500  Gm.  (§x-xvj)  of  milk,  to  be  followed 
after  two  hours  by  meat  broth  or  gelatinous  soup,  with  one 
or  two  yolks  of  egg;  after  three  to  four  hours,  300  to  500 
Gm.  (Bx-xvij),  and  at  night  300  to  800  Gm.  (§x-xxvj)  of 
boiled  rice  pudding. 

Diet  List  for  Chronic  Gastritis  (Friedentv^ald  axd  Ruhrah) 

Calories. 

8.00  a.m.      200  Gm.  milk,  flavored  with  tea 135 

60  Gm.  stale  bread  (1.54)  with  40  Gm.  butter  (326)  480 

1  soft-boiled  egg 80 

10.00  A.M.      100  Gm.  scraped  beef  (119)  with  60  Gm.  stale  bread 

or  toast (154) 273 

Or  chicken  sandwich  (260),  or  50  Gm.  sherry  (60) 
with  egg  (80). 

11.00  a.m.      Bouillon  with  egg 84 

100  Gm.  chicken 106 

Or  100  Gm.  lamb  chops  (230),  or  broiled  steak  (209). 

100  Gm.  spinach 166 

100  Gm.  mashed  potatoes 127 

100  Gm.  stewed  apples 53 

60  Gm.  toast 154 

4.00  p.m.      120  Gm.  milk,  with  tea 81 

30  Gm.  crackers 102 

7.00  P.M.        60  Gm.  stale  bread  (154)  with  40  Gm.  butter  (326)  480 

200  Gm.  milk 135 

2456 
Diet  for  Chronic  Gastritis  (Boas) 

Calories. 

8.00  A.M.      200  Gm.  milk  and  flour  soup  (100  Gm.  milk)     .      .  121.5 

50  Gm.  bread 129.4 

30  Gm.  butter 213.9 

10.00  A.M.         2egg.s 160.0 

.")OGm.  white  bread,  30  Gm.  butter       ....  343.3 
Or  50  Gm.  white  broad,  30  Gm.  Initter,    GO  Gm. 
scraped  beef. 

12.00   M.        200  Gm.  farina  milk  .soup 227.2 

200  Gm.  milk  and  rice 353.4 

100  Gm.  prunes 44.0 


TREAT  MEXT   OF  GASTRITIS  AND  ACHYLIA   GASTRIC  A      377 

Calories. 

3.00  P.M.       200  Gm.  milk  and  tea,  or  milk  and  coffee  (150  Gm. 

milk)         101.2 

50  Gm.  white  bread 129.4 

7.00  p.m.      200  Gm.  rice  and  milk  soup 335.4 

50  Gm.  zwieback 178.9 

2337.6 
Diet  for  Chroxic  G.astriti.s  (Bo.\s) 

Calories 
8 .  00  A.Ai.      200  Gm.  milk  with  40  Gm.  cocoa,  30  Gm.  .sugar      .       462 . 0 

50  Gm.  cakes 187.0 

Or  40  Gm.  zwieback  (178.9). 

10.00  a.m.        50  Gm.  bread  with  30  Gm.  butter 343.0 

100  Gm.  calf  s  brain 140.0 

Or  100  Gm.  sweetbread  (90)  or  broiled  rockfish 
(71.75). 
12.00  m.         Soup  of  30  Gm.  tapioca,  10  Gm  butter      .      .      .       282.0 

100  Gm.  noodles  and  1  egg 352.6 

Or  100  Gm.  spinach  (165 .  65),  100  Gm.  puree  of 
beans  (193),  100  Gm.  carrots  (40),  50  Gm. 
mashed  potatoes  (63.7). 

100  Gm.  breast  of  young  chicken 106.4 

Or  100  Gm.  veal  chops  or  stewed  veal,  pigeon, 
venison,  or  fish. 
100  Gm.  farina,  omelet  or  egg,  pancake  wdth  ham        288 . 0 
3.00  p.m.      100  Gm.  milk  and  tea,  with  28  Gm.  sugar     .      .      .        147.2 

25  Gm.  cakes 93.5 

7.00  P.M.        50  Gm.  wheat  bread  wath  30  Gm.  butter    .      .      .       343.0 
50  Gm.  scraped  meat 59.5 

Total 2804.2 

Medicinal  Treatment. — Hydrochloric  Acid. — In  the  treatment 
of  chronic  gastritis,  medicaments  occupy  a  secondary  place 
compared  with  diet  and  hygiene.  Of  the  drug  agents, 
hydrochloric  acid  is  most  important  and  most  frequently 
employed,  the  object  of  its  use  being  to  supplement  the 
deficiency  of  the  gastric  juice.  (See  Hydrochloric  Acid  and 
Pepsin,  page  166.)  Hydrochloric  acid  was  introduced  to 
the  profession  as  a  factor  in  the  treatment  of  gastritis  by 
Leube.  Ewald  states  that  in  all  cases  characterized  by  a 
diminution  or  absence  of  hydrochloric  acid  the  dilute 
hydrochloric  acid  of  the  Pharmacopoeia  should  be  admin- 
istered in  large  doses,  40  to  60  drops,  three  times  a  day. 


378  CHRONIC  GASTRITIS 

The  best  way  to  give  hydrochloric  acid  is  to  add  from  6 
to  12  drops  of  the  dilute  acid  to  a  glassful  of  water,  to  be 
taken  three  times  a  day,  half  an  hour  after  meals — not  the 
whole  glass  at  one  time,  but  in  three  portions  at  intervals  of 
one-quarter  to  one-half  hour  (Einhorn) .  Pepsin  is  frequently 
given  in  combination  with  hydrochloric  acid,  0.06  Gm. 
(1  grain)  three  times  a  day.  Since  it  has  been  found  that 
in  the  majority  of  cases  of  diminished  gastric  secretion  there 
is  still  a  sufficient  quantity  of  pepsin  secreted,  many  writers 
are  opposed  to  the  administration  of  medicinal  pepsin. 
Pepsin  assists  in  the  process  of  proteolysis  by  catalysis,  that 
is,  without  itself  becoming  used  up  or  diminished  in  quantity. 
Perry^  says  that  the  disrepute  into  which  hydrochloric 
acid  has  fallen  is  due  to  its  having  been  used  in  insufficient 
doses,  and  that  there  has  been  no  practicable  method  by 
which  larger  doses  could  be  given.  The  amount  of  hydro- 
chloric acid  formed  in  the  stomach  daily  has  been  calculated 
to  be  equal  to  12  grammes  of  hydrochloric  acid,  c.  p.,  or 
36  grammes  of  strong  liquid  hydrochloric  acid.  On  the 
basis  of  the  amount  required  to  combine  with  225  grammes 
of  cooked  beef,  the  dose  would  be  15  Gm.  (5iv)  of  liquid 
hydrochloric  acid.  This  amount  could  not  possibly  be  given 
in  less  than  50  ounces  of  water,  an  impossible  quantity. 
When  protein  is  digested  with  hydrochloric  acid,  an  organic 
hydrochloric  acid  combination  is  formed,  which  in  contact 
with  pepsin  is  changed  into  peptone.  For  the  digestion  of 
100  grammes  of  boiled  beef  10  grammes  of  liquid  hydro- 
chloric acid  are  required.  On  the  addition  of  pepsin,  the 
hydrochloric  acid  will  dissolve  65  per  cent,  of  the  beef  with 
which  it  is  combined  and  an  additional  40  per  cent,  of  the 
beef  with  which  it  is  mixed.  This  kind  of  acidity  exists 
normally  in  the  small  intestine,  and  does  not  interfere  with 
the  action  of  pancreatic  juice.  By  preparing  such  a  protein 
combination  from  the  action  of  hydrochloric  acid  on  beef, 
we  may  employ  doses  as  high  as  2  grammes  of  strong 
hydrochloric  acid  without  injury  or  discomfort.  One  heap- 
ing  tablespoonful    of    such   a    preparation    carries    about 

'  Pacific  Medical  Journal,  May,  1903. 


TREAT  MEXT  OF  GASTRITIS  AND  ACIIYLIA   (i  AST  RICA      379 

1  gramme  of  strong  hydrochloric  acid  in  the  proper  condition 
to  digest  the  meat  with  which  it  is  combined  together  with 
40  per  cent,  of  additional  protein.  Besides  what  is  dissolved, 
a  part  of  the  residue  is  converted  into  albumose,  which  is 
readily  digested  by  the  pancreatic  juice.  This  organic 
combination  of  hydrochloric  acid  is  made  by  heating  to- 
gether, till  a  paste  is  formed,  1  part  of  strong  hydrochloric 
acid,  50  parts  of  water,  and  16  parts  of  boiled  beef  ground  to 
a  coarse  consistency.  Prepared  in  this  manner  the  product 
contains  about  7  per  cent,  of  strong  hydrochloric  acid. 
In  case  it  becomes  necessary  to  continue  the  use  of  large 
doses  of  hydrochloric  acid,  it  is  well  to  give,  one  hour  before 
meals,  one-half  as  much  bicarbonate  of  soda  as  the  weight 
of  strong  hydrochloric  acid  that  is  to  be  given. 

"^Tienever  the  gastric  secretion  shows  an  absence  of  free 
hydrochloric  acid,  and  it  can  be  concluded  that  this  is  not 
due  to  atrophy  of  the  mucosa,  one  of  the  most  efficacious 
means  of  restoring  the  secretion  is  by  lavage  with  a  solution 
of  hydrochloric  acid,  3  or  4  parts  to  1000  of  warm  water. 
As  many  of  these  cases  require  lavage,  it  is  expedient  to 
make  use  of  this  solution  even  if  there  is  no  stagnation; 
the  lavage  is  not  intended  here  so  much  for  cleansing  the 
stomach  as  for  stimulating  the  mucosa. 

The  diet  may  consist  largely  of  foods  requiring  consider- 
able amounts  of  hydrochloric  acid  for  digestion,  as  these 
contain  'the  substances  that  are  the  most  effective  stimulants 
to  the  gastric  secretion — finely  minced  or  scraped  beef, 
mutton,  fish,  and  soft-boiled  eggs.  The  extractive  materials 
of  beef  (as  in  beef  tea)  are  also  stimulants.  The  stomachs 
of  these  patients  require  dietetic  gymnastics  (always  exclud- 
ing dilatation,  atrophy,  and  neoplasm),  and  too  bland  or 
sparing  a  diet  wdll  simply  permit  the  secreting  cells  to  atrophy 
from  lack  of  work. 

In  deficient  gastric  secretion  the  digestive  ferments  are 
sometimes  administered.  It  was  customary  at  one  time 
to  administer  hydrochloric  acid  and  pepsin  in  every  case 
of  gastritis.  Now,  after  repeated  experiments,  we  know  that 
when  free  hydrochloric  acid  is  present  there  is  also  sufficient 


380  CHROXIC  GASTRITIS 

pepsin  in  the  stomach;  even  when  hydrochloric  acid  is 
absent,  pepsin  or  pepsinogen  will  be  found  to  be  present. 
Cases  in  which  pepsinogen  is  absent  are  exceedingh-  rare 
(Riegel).  Generally  speaking,  then,  the  administration  of 
pepsin  is  seldom  indicated.  In  cases  where  there  is  a  com- 
plete absence  or  great  deficiency  of  the  peptic  ferment,  pure 
pepsin  in  powder  form  ma}^  be  given.  AMien  there  is  an 
absence  of  hj^drochloric  acid  secretion,  but  pepsinogen  is 
present,  only  hydrochloric  acid  need  be  administered. 

Papain  and  papayotin  are  made  from  the  milk  juice  of 
Carica  papaya,  a  tropical  plant.  These  preparations  possess 
distinct  proteolytic  properties  and  are  active  in  neutral, 
weakly  acid,  or  even  alkaline  solutions.  Papayotin  pep- 
tonizes protein  foods.  These  ferments  are  indicated  in 
deficient  proteolysis  with  absence  of  hydrochloric  acid,  in 
achylia  gastrica,  and  in  acute  gastritis  accompanied  by 
subacidity  or  anacidity.  Papayotin  and  papain  are  not 
adequate  substitutes  for  pepsin  and  hydrochloric  acid;  they 
are  probably  non-essential  as  remedial  agents.  They  are 
contraindicated  in  ulcer  and  in  hyperacidity.  The  dose  is 
0.3  to  1  Gm.  (5  to  15  grains)  after  meals. 

Pancreatin. — Boas  and  others  have  recorded  favorable 
results  from  the  administration  of  pancreatin  in  cases  of 
achylia  gastrica,  subacid  and  anacid  gastritis,  and  gastric 
carcinoma.  Pancreatin  was  first  prepared  by  Engesser, 
Boas  recommends  the  administration  of  pancreatin  in 
tablet  form,  1  to  2  Gm.  (15  to  30  grains)  in  combination  with 
sodium  bicarbonate,  since  pancreatin  is  active  only  in  a 
neutral  or  weakly  alkaline  medium.  The  preparation  should 
be  administered  a  quarter  of  an  hour  after  meals.  The  indi- 
cation for  pancreatin  in  an  anacid  stomach  consists  in  the 
fact  that  intestinal  digestion  is  thus  permitted  to  begin  even 
before  the  ingested  food  passes  into  the  intestine  (see  p.  175). 

Stomachics. — We  have  a  number  of  remedies  which  possess 
the  property  of  stimulating  the  appetite,  and  others  which 
stimulate  the  secretory  and  motor  functions  of  the  stomach. 
Our  knowledge  of  the  action  of  this  class  of  drugs  is  largely 
empirical.     Loss  of  appetite  is  an  indication  for  the  admiu- 


TREAT  MEST  OF  GASTRITIS  AND  ACHY  LI  A   (J  AST  RICA      3S1 

istration  of  stomachics,  or  bitters,  as  they  are  called.  Riegel 
reports  the  results  of  experiments  of  Bokai,  who  found  that 
quassia  and  calumba  were  capable  of  increasing  the  secre- 
tion of  gastric  juice  by  their  direct  effect  on  the  mucous 
membrane  of  the  stomach. 

According  to  Reichmann,  who  has  made  very  careful 
investigations  on  human  subjects,  bitter  remedies  should  be 
administered  only  in  cases  in  which  the  secretory  powers 
of  the  stomach  are  reduced;  when  prescribed,  the  prescrip- 
tion should  specify  half  an  hour  before  meals  as  the  time 
for  taking  the  dose.  Fawitzky  agrees  with  Reichmann  in 
regard  to  vegetable  bitters,  both  as  to  their  advisability 
and  as  to  the  time  of  their  administration;  he  asserts  that 
they  act  beneficially  on  the  secretion  of  gastric  juice  in 
cases  where  there  is  a  reduced  secretion  of  hydrochloric  acid. 

The  administration  of  the  so-called  bitter  tonics,  gentian, 
condurango,  quassia,  and  nux  vomica,  has  been  found  very 
helpful  in  chronic  gastritis.  The  fluid  extract  of  condurango, 
calumba,  or  quassia  is  to  be  taken  in  20-drop  doses  three 
times  a  day.  Tincture  of  nux  vomica  may  be  prescribed 
in  10-drop  doses  three  times  a  day,  either  alone  or  in  com- 
bination with  the  drugs  mentioned.  These  remedies  are  best 
given  a  ciuarter  of  an  hour  before  meals,  in  a  little  water. 
Their  physiologic  action  is  not  well  understood.  Riegel 
beheves  the  favorable  effect  of  the  so-called  bitter  tonics 
or  stomachics  is  due  to  their  peculiar  taste  rather  than  to 
any  direct  influence  on  the  gastric  mucous  membrane.  He 
maintains  that  the  action  of  the  bitters  begins  with  the  sense 
of  taste,  before  the  medicine  actually  reaches  the  stomach. 
Pawlow  holds  similar  opinions  regarding  the  action  of  these 
drugs. 

The  following  is  a  useful  combination  of  hydrochloric  acid 
with  the  bitters: 

Gm.  or  Cc. 

I^ — Tin cturae  nucis  vomicae 12.0         oiij 

Tincturse  cinchonse  compositae 16.0         oSS 

Acidi  hydrochlorici  diluti 16.0         o^s 

Aquae  destillatae q.  s.  ad      120.0        §iv 

Misce. 

Sig. — One  to  two  teaspoonfuls  in  water  one-half  hour  after  meals,  three 
times  a  day. 


382  CHRONIC  GASTRITIS 

Nausea  and  vomiting  may  be  controlled  by  administering 
cerimn  oxalate,  0.065  to  0.325  Gm.  (1  to  5  grains),  alone  or 
in  combination  with  bismuth  subnitrate  or  sodium  bicar- 
bonate, or  by  the  methods  mentioned  under  "Acute  Gas- 
tritis." 

Fermentation  may  be  checked  by  the  use  of  antiseptic 
agents,  to  which  a  carminative  may  be  added  in  cases  of 
flatulence.  Habershon  recommends  as  a  palliative,  in  con- 
ditions where  fermentation  and  flatulence  are  present,  a 
pill  of  phenol  0.06  Cc.  (1  minim)  with  rhubarb  and  traga- 
canth  powder.  Hydrochloric  acid  alone  may  be  sufficient; 
if  not,  some  antiseptic  must  be  employed,  such  as  resorcinol, 
saccharin,  salicylic  acid,  salicylate  of  bismuth,  menthol, 
thymol,  benzol.  These  drugs  are  best  given  before  meals, 
either  alone  or  in  combination  with  other  remedies. 

Gm.  or  Cc. 
I^ — Bismuthi  salicylatis 20 . 0        3  v 

Resorcinolis 4.0         5j 

Sodii  salicylatis, 

Salolis aa       2.0         oss 

Misce. 

Sig. — One-third  teaspoonful  three  times  daily.     (Wegele.) 

Gm.  or  Cc. 

I^ — Thymohs, 

Resorcinolis aa       0 .  75       gr.  xij 

Extract!  gentians' q.  s. 

Misce  et  ft.  pil.  no.  xx. 

Sig. — One  oi-  two  pills  before  meals.    (Roderi.) 

Gm.  or  Cc. 

H— Resor.-inolis 0  1         gr.  ij 

Sacchurini 0.02       gr.  ^ 

Misce  et  ft.  pulv.  no.  i. 

Sig. — One  powder  half  an  hour  before  meals.     (Eicbhorst.) 

Gm.  or  Cc. 

rj— Mentholis 10         V-r.w 

Alcoholis 20.0        ov 

Syrupi 30.0         oj 

Mi.sce. 

Sig. — One  teasi)oonfui  every  liour  until  relieved.    (Wegele.) 

The  so-called  bitters  may  be  employed  with  advantage  in 
all  organic  or  nervous  disorders  of  the  stomach  in  which 


TREATMENT   OF  GASTRITIS  AND  ACHYLIA   GASTRIC  A     383 

anorexia  is  a  symptom,  especially  when  it  is  accompanied 
by  diminished  gastric  secretion. 

Penzoldt  has  recommended  orexin  (phenyldihydrochina- 
zolin  hydrochloride)  as  a  stomachic  (see  p.  189).  It  is  said 
to  possess  the  property  of  inducing  hunger.  Orexin  acts 
as  an  irritant  to  the  gastric  mucosa;  it  would,  therefore, 
be  contraindicated  in  irritable  conditions  of  the  stomach. 
Steiner  later  introduced  the  tannate  of  the  same  base,  which 
was  claimed  to  be  less  irritating  than  the  original  product. 
The  adult  dose  is  0.3  to  1  Gm.  (5  to  15  grains)  in  capsule, 
with  J  liter  of  water,  one  to  two  hours  before  meals. 

Creosote  has  also  been  placed  among  the  stomachics. 
It  causes  energetic  peristalsis  and  slightly  increases  the 
secretion.  It  is  especially  useful  in  the  gastritis  of  tuber- 
culosis. Klemperer  recommends  a  mixture  proposed  by 
Bouchard-Frantzel : 

Gm.  or  Cc. 

I^— Creosoti 12.0  3iij 

Tincturae  gentianse 20.0  3v 

Vini  xerici 800 . 0  §  xxv 

Alcoholis 200.0  5vj 

Misce. 

Sig. — Teaspoonful  before  meal.=i. 

Resorcinol  has  a  stimulating  effect  on  the  appetite,  as 
has  been  demonstrated  by  clinical  experience.  It  is  best 
taken  in  solution,  either  pure  or  combined  with  other 
bitters : 

Gm.  or  Cc. 

I^ — Fluidextracti  condurango 16.0  §s? 

Resorcinolis 4.0  3j 

Misce. 

Sig. — Thirty  drops  four  times  a  day. 

Gastrosan  is  a  preparation  of  salicylic  acid  and  bismuth 
(bismuth  bisalicylate) .  It  contains  40  to  50  per  cent,  of 
oxide  of  bismuth  and  50  to  52  per  cent,  of  salicylic  acid. 
The  saUcylic  acid  is  liberated  in  the  stomach  under  the 
influence  of  warmth  and  the  gastric  processes,  and  is  then 
able  to  exert  its  antizymotic  effects. 

The  gastric  secretion  persists  to  a  slight  degree  in  chronic 


384 


CHRONIC  GASTRITIS 


atrophic  gastritis  and  in  the  severe  forms  of  chronic  gas- 
tritis where  the  mucous  membrane  has  undergone  structural 
or  atrophic  change,  though  the  quantity  of  hydrochloric 
acid  secreted  may  be  very  small.  Patients  may  be  allowed 
meat,  very  finely  divided.  An  effort  should  be  made  to 
increase  the  secretory  powers  of  the  stomach  by  prescribing 
a  dietary  adapted  to  this  purpose.  Strauss  recommends 
meat  extractives  and  condiments;  he  advocates  bouillon, 
which  may  be  made  more  concentrated  by  the  addition  of 
Liebig's  extract  of  beef,  as  the  first  course  for  dinner.  Car- 
bonated waters  and  coffee  act  in  a  similar  manner.  The 
latter,  however,  should  be  indulged  in  very  sparingly. 
The  mode  of  preparation  and  of  serving  the  food,  if  attrac- 
tive, will  have  a  stimulating  action  on  the  gastric  functions. 
The  supply  of  beverages  should  be  limited,  especially  during 
the  meal,  in  order  to  avoid  a  further  dilution  of  the  gastric 
ferments  which  are  present  only  in  small  quantities. 

The  following  dietary  tables  will  be  found  useful  in  these 
conditions  (Riegel) : 


Carbo- 

Protein. 

Fat. 

hydratea. 

Alcohol 

Morning. 

150  Gm.  cocoa 
25  Gm.    butter    (on 

8.0 

6.0 

7.5 

toast)   .... 

0.18 

20.8 

0.15 

Forenoon. 

1  soft-boiled  egg     . 

6.0 

5.0 

Noon. 

200      Gm.      oatmeal 

gruel      .... 

12.5 

0.3 

18.0 

150  Gm.  fowl 

28.0 

13.5 

1.8 

200  Gm.  carrots    . 

2.14 

0,4 

16.3 

Afternoon. 

150  Gm.  cocoa 

8.0 

6.0 

7.5 

25  Gm.  butter    .      . 

O.IS 

20.8 

0.15 

Evening. 

200  Gm.  barley  soup 

3.2 

6.0 

17.0 

1  egg      ...      . 

6.0 

5.0 

100  Gm.  minced  hum 

25.0 

8.0 

100  Gm.  macaroni 

9.0 

0.3 

76.7 

During  Llic 

200  Gm.  wine 

6.0 

16.0 

day. 

75  Gm.  zwieback 

9.0 

1.5 
93.6 

63.9 

117.2 

215.0 

190.0 

Galories  (approximately 

)     480 

890 

970 

100 

Total  number  of  calories,  2440. 

TREATMENT  OF  GASTRITIS  AND  AC'HYLIA  GASTRICA      385 


Morning.       500     Gm.    milk,     3 

zwieback 
10  A.M.  Oatmeal  gruel,  with  1 

yolk  of  egg 
Noon.  Rice  soup,  with  ]  yolk 

of  egg     . 
200  Gm.  beefsteak 
25  Gm.  toast 
100  Gm.  mashed  po- 
tatoes   .... 
Afternoon.     250  Gm.  milk  cocoa, 
3     zwieback     with 
jam        .      .      .      . 
Supper.  Rice     pudding     pre- 

pared with  500  Cc. 
milk  and   30   Gm. 
sugar     .      .      .      . 
25  Gm.  toast 


Protein. 

20.6 
5.3 

4.5 

42.8 
2.0 

2.2 
13.5 


24.4 

2.2 


Fat. 

20.2 

5.2 

9.2 

10.4 

0.2 

5.1 
15.8 


18.8 
0.2 


Carbo- 
hydrates. 

45.7 

14.2 
15.2 
19.0 
17.0 

44.6 


130.8 
19.0 


Calories. 

461 

129 

167 

272 

90 

125 
385 


812 
90 


Carbo- 

Protein. 

Fat. 

hydrates. 

Calories 

Morning. 

Milk  cocoa  (20  Gm. 
cocoa,      10      Gm. 
sugar,     250     Gm. 

milk)      .... 

10.3 

18.2 

25.7 

321 

10  A.M. 

50  Gm.  toast 
100  Gm.     breast     of 
young     chicken 

4.3 

0.5 

39.0 

160 

(weighed  raw)  . 

19.6 

2.8 

106 

30  Gm.  butter    .      . 

23.0 

214 

Noon. 

Potato  soup  (100  Gm. 
potatoes,    50    Gm. 
milk,  50  Gm.  flour, 

5  Gm.  butter)   . 

3.5 

6.0 

23.1 

165 

Veal  hashed  (200  Gm. 

raw)       .... 

42.8 

10.4 

272 

150     Gm.     macaroni 

(50  Gm.  uncooked) 

4.2 

6.4 

38.0 

232 

Evening. 

Soup    (30   Gm.  tapi- 

oca, 10  Gm.  butter) 

7.0 

14.0 

30.0 

282 

Supper. 

250  Cc.  milk,  2  zwie- 

back     .... 

10.9 

10.5 

26.3 

250 

Total  number  of  calories 

2002 

25 


386 


CHRONIC  GASTRITIS 


Diet  List   (Wegele) 

Protein.  Fat. 

Morning.       200  Gm.  cocoa 7.2  8.0 

20  Gm.  cream       .....       0.7  5.5 

15  Gm.  butter 0.1  12.5 

30  Gm.  toast 4.5  0.5 

Forenoon.      200  Gm.  oatmeal  gruel     .      .      .       3.0  6.0 

15  Gm.  zwieback       .      .      .      .       6.5  1.6 

15  Gm.  butter 0.1  12.5 

Noon.             150  Gm.  fowl 13.5  1.8 

200  Gm.  rice  and  vegetables        .       0.4  10 . 0 

200  Gm.  pudding 13.5  24.2 

50  Gm.  apple  sauce  .      .      .      .       0.7  .... 

Afternoon.     200  Gm.  cocoa 7.2  8.0 

20  Gm.  cream 0.7  5.5 

50  Gm.  white  bread  .      .      .      .       4.5  0.5 

15  Gm.  butter 0.1  12.5 

Evening.        200  Gm.  oatmeal  gruel      .      .      .       3.2  6.0 

100  Gm.  macaroni       ....       9.0  0.3 

100  Gm.  cold  roast  meat  .      .      .     24.0  36.5 

90.1  151.9 

Calories 403  1400 

Total  combustive  value,  3033  calories. 


Carbo- 
hydrates. 

10.0 
0..7 

30.0 
14.0 
41.0 


16.3 
46.0 

6.5 
10.0 

0.7 
30.0 

15.0 
76.7 


296.9 
1230 


Diet  List  (Zweig) 


Calories. 

370.4 


Early.  200  Cc.  milk  soup,  50  Gm.  zwieback,  10  Gm.  butter 

Forenoon.      2  eggs  or  oatmeal  soup  (20  Gm.  oatmeal  and  1  egg), 

50  Gm.  ham  (minced),    50  Gm.  toast,  20  Gm. 

butter 420.0 

Noon.  200  Gm.  rice-milk  soup,  150  Gm.  minced  meat  (of 

chicken,  squab,  beefsteak,  calf's  brain,  sweet- 
bread, fish),  100  Gm.  vegetable  pur^e  (spinach, 
potatoes,  carrots,  green  peas),  50  Gm.  toast     .      .       757.8 

Afternoon.     Same  as  early 370 . 4 

Evening.        Milk  pudding  (250  Gm.  milk,  20  Gm.  tapioca,  sago 

or  oatmeal,  15  Gm.  sugar),. 50  Gm.  toast    .      .      .       300.0 

Total 2218.6 


TREATMENT  OF  GASTRITIS  AND  ACHYLIA   GASTRICA      387 


Early. 
Forenoon. 


Noon. 


Afternoon. 
Evening. 


Diet  as  Impuovkment  Proceeds  (Zweig) 

Calories. 

2.50  Gm.  milk  cocoa,  50  Gm.  toast,  20  Gm.  butter  .  556.4 
2  eggs  or  oatmeal  soup  (20  Gm.  oatmeal  and  1  egg), 

50  Gm.  ham  (minced),   50  Gm.  toast,   20  Gm. 

butter 420.0 

200  Gm.  leguminous  flour  souj)  with  1  yolk  of  egg; 

meat  and   vegetable  puree  as  above;    1  omelet 

souffl6    (2  eggs,  10  Gm.  butter,   10  Gm.  sugar) 

or  100  Gm.  rice  custard,  or  pancake  and  ham; 

50  Gm.  toast 912.4 

Same  as  early 556 . 4 

2  eggs  soft  boiled  or  scrambled,  or  50  Gm.  minced 

meat;  leguminous  meal  soup  with  1  yolk  of  egg; 

50  Gm.  toast 567.4 

Total 3012.6 


Diet  of  Boas 

Calories. 

7 .  00  A.M.      200  Gm .  milk  with  40  Gm.  cocoa  and  30  Gm.  sugar  462 . 0 

50  Gm.  biscuits  or  zwieback 187.0 

10.00  a.m.        50  Gm.  white  bread,  30  Gm.  butter       ....  343.0 

One  egg  or  50  Gm.  minced  ham 100.0 

1.00  p.m.      Soup  (30  Gm.  tapioca,  10  Gm.  butter)     ....  352.6 
One  egg,  100  Gm.  noodles  or  spinach,  100  Gm. 
bean  puree,  100  Gm.  carrots,  50  Gm.  mashed 

potatoes 282.0 

100  Gm.  breast  of  young  chicken,  veal  cutlet,  or 

veal  (steamed),  or  100  Gm.  squab,  game,  or  fish  106.4 

100  Gm.  rice  omelet,  or  omelet  with  ham     .      .      .  288.0 

4.00  p.m.      100  Gm.  milk  with  tea,  20  Gm.  sugar      ....  147.5 

25  Gm.  biscuits 93.5 

8.00  p.m.        50  Gm.  wheat  bread,  30  Gm.  butter      ....  343.0 

50  Gm.  minced  meat 59.5 

Total 2765.4 


In  these  conditions — namely,  when  the  gastric  secretion 
is  present  in  small  quantities  only — hydrochloric  acid  and 
pepsin  constitute  the  principal  medicinal  agents.  They  are 
employed  in  the  same  manner  as  in  the  treatment  of  achyUa. 

In  chronic  gastritis  when  the  secretion  is  of  normal  or  but 
slightly  diminished  acidity,  as  in  the  severer  forms,  diet  is 
the  paramount  factor  in  treatment.  By  dietary  measures 
alone  it  is  frequently  possible  to  restore  the  digestion  to 


388  CHRONIC  GASTRITIS 

normal;  the  diet  indicated  in  subacidity,  and  already- 
described,  should  be  prescribed.  It  is  important,  especially 
in  the  initial  period  of  treatment,  that  the  food  be  finely 
divided  and  thoroughly  masticated.  The  patient  should 
not  be  restricted  in  the  quantity  and  kind  of  food  so 
long  as  the  food  is  subjected  to  thorough  mastication  and 
insalivation.  In  fact,  only  such  articles  of  diet  need  be 
interdicted  as  cannot  be  finely  subdivided.  Strong  stimu- 
lants and  condiments  should  be  prohibited,  inasmuch  as  they 
are  not  required  to  stimulate  gastric  secretion;  by  their  use 
this  form  of  chronic  gastritis  may  be  converted  into  an  acid 
gastritis. 

Drug  treatment,  when  considered  expedient,  consists  of 
the  bitters  or  stomachics  for  poor  appetite,  and  antiseptic 
measures  when  fermentative  processes  are  present.  Astrin- 
gent remedies,  such  as  nitrate  of  silver,  are  of  value  in  cases 
in  which  there  is  a  profuse  secretion  of  mucus. 

White  and  Eyre^  report  a  case  of  gastritis  occurring  in  a 
female,  aged  thirty-six  years,  who  for  over  eight  months  had 
had  nausea,  heartburn,  chilliness,  slight  rise  in  temperature, 
and  who  was  severely  ill  when  seen- — completely  incapaci- 
tated in  fact.  The  attacks  were  attended  by  constipation, 
and  the  patient  had  lost  much  flesh.  Different  physicians 
had  diagnosticated  duodenal  ulcer  and  atonic  dilatation  of 
the  stomach.  Stomach  washings  contained  many  colon 
bacilli,  from  which  a  vaccine  was  prepared  and  administered 
(see  p.  452).  After  the  first  injection  the  patient  showed 
improvement,  and  after  five  months'  treatment  she  had 
gained  almost  15^  pounds  in  weight,  her  appetite  was  good, 
and  she  felt  perfectly  well.  When  seen  seven  months  later 
she  was  doing  well  and  had  had  no  further  attacks. 

Treatment  by  Gastric  Lavage. — Gastric  lavage  is  indicated  in 
cases  of  chronic  gastritis  in  which  there  is  mucus-secre- 
tion, disturbance  in  motility,  or  fermentative  j)rocesses. 
Mucus  should  be  removed  by  lavage  in  the  early  morning 
when   the  stomach  is  empty.     It   is  well   to  elevate   the 

'  H.  W.  Stoner,  A  R<^sum6  of  Vaccine  'riicniiJ.v,  AiiuTicaii  Jouriuil  of  the 
Medical  Sciences,  Februiuy  11,  1!>11. 


TREATMENT  OF  GASTRITIS  AND  ACIIYLIA   GASTRIC  A      389 

irrigator  and  thus  allow  the  water  to  enter  the  stomach 
with  a  certain  amount  of  force.  Not  more  than  eight  ounces 
of  water  should  be  used  at  one  time.  Richter's  stomach 
douche  is  recommended  for  these  cases  (see  p.  129).  The 
frec^uency  with  which  gastric  lavage  should  be  practiced 
must  be  determined  by  the  amount  of  mucus  in  the  stomach 
contents,  the  adequacy  of  response  to  diet  and  treatment, 
and  the  manner  in  which  the  patients  bear  the  washing- 
out  process.  There  can  be  no  fixed  rule  to  apply  to  all 
cases.  Too  frequent  lavage  is  apt  to  do  more  harm  than 
good.  It  may  be  w^ell  to  give  several  daily  treatments  and 
thereafter  two  or  three  a  week,  soon  lessening  the  frequency. 

Mucus-dissolving  drugs  may  be  added  to  the  water  after 
all  food  particles  have  been  removed.  Alkalies  which  dis- 
solve mucus  are:  Solution  of  common  salt  (1  per  cent.) ;  lime 
water  (5  teaspoonfuls  to  1  liter  of  water) ;  bicarbonate  of 
soda  (1  per  cent.) ;  Fleiner's  compound  (a  mixture  of  sodium 
chloride  and  sodium  carbonate  in  the  proportion  of  2  to  1), 
a  heaping  teaspoonful  to  2  or  3  liters  (quarts)  of  water; 
further,  Carlsbad  or  Vichy  salts,  2  teaspoonfuls  to  1  liter 
(quart);  or  Carlsbad  water,  Ems  water,  or  other  mineral 
waters  having  mucus-solvent  properties. 

Plain  lukewarm  water  may  be  used  uiitil  the  stomach  is 
cleansed  of  food. 

At  the  termination  of  lavage  distilled  water  should  be 
employed  to  clear  the  stomach,  and  a  weak  solution  of  silver 
nitrate  (2  to  4  grains  to  the  ounce)  introduced  through  the 
tube  and  allowed  to  flow  out  again.  There  seems  no  better 
application  than  silver;  but  hydrastis  should  be  employed 
at  some  sittings,  and  resorcinol  solution  (5  grains  to  Sviij) 
at  others.  Although  unpleasant  in  odor,  there  is  no  agent 
that  excels  ichthyol  water  as  a  lavement.  With  resorcinol 
it  seems  to  exert  a  regenerating  efTect  upon  epithelia,  and  is 
an  excellent  antiseptic.  If  fermentation  be  found  in  the 
stomach  contents,  a  few  grains  of  salicylic  acid  in  solution 
may  be  employed  as  a  wash,  and  a  weak  solution  (2  grains 
to  the  pint)  of  potassium  permanganate  may  be  employed 
quite  frequently. 


390  CHRONIC  GASTRITIS 

In  cases  of  disturbed  gastric  motility  lavage  with  luke- 
warni  water  should  be  performed  in  the  evening,  before  the 
evening  meal,  with  the  patient  in  the  recumbent  position. 
The  presence  of  gastric  fermentation  calls  for  antiseptic 
solutions:  Boracic  acid,  3  to  5  to  1000;  salicylic  acid,  1  to  3 
to  1000;  thymol,  1  to  1000;  lysol,  1  to  1000;  sahcjdate  of 
soda,  5  to  1000;  resorcinol  resublimate,  1  to  100;  silver 
nitrate,  1  to  1000;  or  permanganate  of  potash,  1  to  1000  to 
1  to  5000.  The  most  efTective  drug  to  destroy  fermentative 
germs  is  salicylic  acid. 

In  chronic  gastritis  with  anorexia  in  which  lavage  is 
practiced,  it  is  advisable  to  wash  out  the  stomach  with,  solu- 
tions containing  the  bitters,  such  as  quassia,  30  Gm.  (§j), 
macerated  for  one  night  with  ^  liter  (1  pint)  of  cold  water, 
and  filtered  early  the  morning  of  the  lavage;  hop  tea 
(infusion  of  dried  hops,  humulus  lupulus);  or  condurango 
(1  to  2  dessertspoonfuls  of  fluidextract  condurango  to  ^ 
liter  of  warm  water).  These  solutions  act  at  the  same  time 
as  stimulants  to  the  mucous  membrane  and  are  particularly 
applicable  in  subacid  and  anacid  cases. 

In  cases  of  chronic  gastritis  accompanied  bj^  violent 
vomiting,  which  does  not  yield  to  diet  and  ordinary  lavage, 
Cramer  advises  novocaine  after  lavage.  Novocaine  0.3  to 
0.5  Gm.  (5  to  7  grains)  to  ^  liter  of  water  is  introduced, 
and  allowed  to  flow  out  after  having  remained  two  or  three 
minutes  in  the  stomach.  Cocaine  (1  to  500)  may  also  be 
employed  in  such  cases. 

Treatment  with  Mineral  Waters. — Waters  from  the  springs 
of  Saratoga,  Congress,  and  Kissingen  are  particularly  useful 
in  these  gastric  affections.  They  should  be  taken  in  small 
doses  on  an  empty  stomach.  The  artificial  w^aters  may  be 
employed  when  it  is  not  convenient  to  visit  the  various 
resorts. 

Good  results  are  often  obtained  from  the  use  of  sodium 
chloride  waters  in  subacid  chronic  gastritis  and  anacid 
gastritis  with  functionally  active  mucous  membrane.  The 
increase  in  gastric  secretion  is  frequently  so  marked  as  to 


TREATMENT  OF  GASTRITIS  AND  ACHYLIA   GASTRIC  A      391 

result  in  a  decided  improvement  and  amelioration  of  symp- 
toms after  only  a  few  weeks'  treatment. 

Boas  cautions  against  the  employment  of  Carlsbad 
waters  in  cases  of  subacidity,  though  sodium  chloride  waters 
may  be  tried  in  the  later  stages. 

Mineral  water  cures  are  indicated  only  in  those  cases  of 
chronic  gastritis  with  normal  acidity  in  which  the  patients 
complain  of  much  discomfort,  and  in  which  large  quantities 
of  mucus  are  secreted.  These  cases  are  best  treated  by 
springs  similar  to  Carlsbad. 

To  avoid  the  inhibitory  action  of  the  Carlsbad  waters  on 
gastric  secretion,  large  doses  (500  to  600  Cc.)  should  not  be 
prescribed  for  a  period  longer  than  two  weeks,  nor  smaller 
doses  (200  to  300  Cc.)  for  more  than  three  to  four  weeks. 
Carlsbad  water  should  be  taken  warm,  in  the  morning,  on 
the  fasting  stomach,  slowly,  and  in  interrupted  doses. 

Physical  Treatment. — Local  applications  of  heat,  dry  and 
moist,  are  often  of  value  in  allaying  pressure  and  pain. 
Compresses,  thermophores,  Winternitz's  stomach  application 
(the  moist  trunk  packing),  over  night,  are  recommended. 
The  Priessnitz  poultice  is  also  very  valuable  (see  p.  151). 
The  Scotch  douche  is  indicated  in  the  conditions  described 
when  they  are  complicated  with  atony. 

Massage  should  be  adopted  in  cases  not  complicated  with 
pyloric  stenosis,  stagnation,  or  fermentation.  Simple  atony 
is  not  a  contraindication,  but  gastric  pain  is.  As  described 
in  the  chapter  on  Massage,  this  manipulation  should  be 
performed  when  the  stomach  is  empty.  The  purpose  of 
massage  is  to  improve  the  muscle  tonicity  and  the  circulation 
of  the  blood.  Massage,  in  connection  with  the  use  of 
medicinal  agents,  as  suggested  by  Wegele,  is  useful  in  some 
conditions;  the  drugs  used  are  the  simple  bitters,  as  in  the 
lavage  process. 

In  chronic  gastritis  with  atony,  electric  treatment  is 
indicated — the  extra  ventricular  faradic  current.  If  there  is 
marked  gastralgia,  intraventricular  galvanization  may  be 
employed. 

When   chronic  gastric  catarrh  can  be  definitely  traced 


392  _  CHRONIC  GASTRITIS 

to  congestive  conditions  related  to  the  portal  system,  or 
to  diseases  of  the  liver,  heart,  or  lungs,  in  which  the  stomach 
shares  in  the  portal  engorgement,  treatment  of  such  condi- 
tions is  especially  indicated.  "WTien  chronic  gastritis  is 
secondary  to  other  chronic  diseases,  such  as  tuberculous 
peritonitis,  these  must  receive  appropriate  treatment. 


CHAPTER    XYIII 

MOTOR  IXSUFFICIENCY:  ATONY  (MYASTHENIA)— DILATATION 

(ISCHOCHYMIA,  GASTRECTASIS)— STENOSIS  OF  THE 

PYLORUS 

At  one  time  the  opinion  prevailed  among  gastroenter- 
ologists  that  abnormaUty  in  size  or  position  of  the  stomach 
was  largely  responsible  for  motor  disturbances.  It  has  been 
found,  however,  that  greatly  dilated  and  ptotic  stomachs 
do  not  of  necessity  produce  any  disturbance  of  function. 
Dilatation  of  the  stomach  assumes  a  pathologic  importance 
only  when  it  interferes  with  evacuation  of  the  gastric  con- 
tents into  the  intestine.  The  stomach  in  health  should 
empty  itself  of  a  small  meal  (test  breakfast)  within  an  hour 
and  a  half,  of  a  large  meal  (.test  dinner)  in  seven  hours. 
The  emptying  process  is,  as  a  rule,  accomplished  within  these 
limits  by  either  atonic  or  normal  stomachs.  In  stomachs 
of  both  normal  and  abnormal  dimensions  the  emptying 
period  may  be  pathologically  altered;  usually  it  is  extended. 
In  comparatively  rare  cases  there  is  hypermotility  in  the 
absence  of  hydrochloric  acid  secretion. 

Rosenbach  introduced  the  term  ''motor  insufficiency"  to 
designate  motor  disturbances  of  the  stomach.  This  term  is 
now  in  general  use. 


MOTOR  INSUFFICIENCY  OF  THE  FIRST  DEGREE 

Boas  has  classified  motor  disturbances  as  motor  insuffi- 
ciency of  the  first  and  second  degrees. 

In  motor  insufficiency  of  the  first  degree  the  evacuation, 
though  complete,  is  retarded. 

Etiology. — Motor  insufficiency  of  the  first  degree  is  con- 
tingent upon  a  primary  relaxation  of  the  muscular  wall  of 


394  MOTOR  INSUFFICIENCY 

the  stomach  (myasthenia,  atony).  Such  muscular  relaxa- 
tion may  result  from  irregular  modes  of  living — the  frequent 
overloading  of  the  stomach  with  food  or  distending  it  with 
fluids;  the  prolonged  use  of  narcotic  drugs  (hypnotics); 
or  excessive  indulgence  in  tobacco.  Idiopathic  and  heredi- 
tary myasthenias  have  been  noted.  Motor  insufficiency  of 
the  first  degree  may  result  from  acute  or  chronic  diseases, 
grave  anemias,  infections,  loss  of  blood,  or  childbirth; 
diseases  of  the  digestive  organs,  as  gastroptosis,  chronic 
gastritis,  nervous  dyspepsia,  chronic  intestinal  catarrh, 
chronic  constipation,  portal  congestion,  or  cholelithiasis, 
may  give  rise  to  primary  atony. 

There  is  a  motor  insufficiency  which  is  designated  second- 
ary; it  is  due  to  obstruction  of  the  pyloric  exit,  and  is  hyper- 
tonic rather  than  atonic,  the  gastric  walls  being  hypertro- 
phied  from  the  peristaltic  movements  of  the  stomach  in  its 
persistent  efforts  to  empty  itself.  (See  Plate  XXI.)  Hyper- 
trophy of  the  pylorus  may  result  from  chronic  gastritis, 
cicatrization  of  ulcers,  slight  torsion  from  gastroptosis,  peri- 
gastric adhesions  an  epigastric  hernias,  hypersecretion  with 
frequent  pylorospasm,  or  repeated  injuries  in  the  region  of 
the  stomach.  The  hypertrophic  changes  in  the  pylorus  in 
such  cases  are  slowly  progressive.  These  cases,  as  a  rule, 
pass  from  mechanical  motor  insufficiency  of  the  first  degree 
to  motor  insufficiency  of  the  second  degree. 

Symptoms. — In  primary  atonic  motor  insufficiency^  of  the 
first  degree  great  discomfort  may  be  experienced  on  the 
partaking'  of  food;  the  pressure  symptoms  and  feeling  of 
fulness  may  persist  for  several  hours,  or  in  severe  cases  as 
long  as  there  is  food  in  the  stomach.  Patients  are  apt  to  be 
annoyed  by  eructations,  with  pyrosis,  when  hyperacidity 
is  present.  The  so-called  "stomach  dizziness"  is  sometimes 
experienced  in  gastric  atony  complicated  with  constipation. 
Patients  may  complain  of  many  symptoms  of  neurasthenia, 
such  as  fulness  in  the  head,  headache,  palpitation  of  the 
heart,  backache,  hypersensitiveness  on  mental  or  physical 
effort. 

The  physician  should  endeavor  to  differentiate  clearlj' 


MOTOR  INSUFFICIENCY  OF  THE  FIRST  DEGREE      395 

between  primary  atonic  motor  insufficiency  of  the  first 
degree  and  motor  insufficiency  of  the  second  degree  (dila- 
tation) induced  directly  by  pyloric  stenosis. 

Diagnosis. — Gastroptosis  and  atony  occur  frequently  in 
the  same  individual.  Gastroptosis  may  sometimes  be 
diagnosticated  by  inspection  when  the  abdominal  walls  are 
thin  and  relaxed  and  the  stomach  is  in  a  condition  of  peri- 
staltic movement.  Permanent  and  absolute  dilatation  of 
the  stomach  does  not  occur  in  primary  atony.  The  atonic 
muscles  may,  however,  be  so  greatly  distended  by  the 
pressure  of  food  as  to  constitute  a  condition  of  transient 
dilatation  of  the  stomach.  Should  a  person  with  a  normal 
musculature  drink  a  sufficient  quantity  of  water,  the  inferior 
border  of  the  stomach  will  descend  to  the  level  of  the 
umbilicus,  as  shown  by  the  area  of  gastric  dulness,  but  no 
low^er.  The  atonic  stomach,  on  the  other  hand,  may  be  so 
distended  by  fluids  as  to  throw  the  lower  border  below  the 
navel.  Splashing  sounds  elicited  when  the  stomach  should 
be  empty  go  to  confirm  a  diagnosis  of  atony.  The  stomach 
in  a  condition  of  atony  contains  food  remnants  six  to  seven 
hours  after  the  ingestion  of  a  Riegel  test  meal.  It,  however, 
empties  itself  completely  during  the  night,  after  a  test 
supper.  One  hour  and  a  half  after  a  test  breakfast  the 
atonic  stomach  is  found  to  contain  food  residues. 

The  motility  and  power  of  evacuation  of  the  stomach 
may  be  demonstrated  by  the  x-rays,  if  a  bismuth  suspen- 
sion be  first  administered  to  render  the  outline  opaque. 
(See  Plates  XV,  XVI,  XVII,  XVIII,  and  XIX.) 

Examination  of  the  stomach  contents  withdrawn  by 
means  of  the  stomach  tube  reveals,  in  atonic  conditions, 
the  presence  of  free  hydrochloric  acid  in  varying  quantities, 
depending  upon  whether  the  case  is  one  of  simple  non- 
comphcated  atony  or  a  complication  of  atony  with  gastritis 
or  hypersecretion.  Should  simple  atony  be  protracted  for 
some  length  of  time,  the  result  may  be  diminished  acid 
secretion.  In  the  absence  of  gastritis  and  hypersecretion 
the  acidity  usually  remains  normal  for  a  long  time,  and  the 
secretion  of  pepsin  and  rennin  remains  normal  for  a  much 


396  MOTOR  IXSUFFICIEXCY 

longer  period.  Constipation  frequently  accompanies  atony 
of  the  stomach. 

Treatment. — The  treatment  of  primary  motor  insufficiency 
of  the  first  degree  should  tend  to  prevent  overdistention  of 
the  stomach  and  at  the  same  time  improve  the  muscle 
tonus.  Much  may  be  accomplished  by  suitable  diet, 
which  should  be  selected  so  as  to  make  the  least  demand 
upon  the  motor  activity  of  the  stomach.  The  meals  should 
be  small  in  quantity  and  comparatively  frequent.  In  regard 
to  the  consistency  of  the  food,  Riegel  maintains  that  the 
motor  condition  of  the  stomach  should  be  the  guide.  In  the 
atonic  as  in  the  normal  stomach  the  liquid  portion  of  the 
food  passes  into  the  duodenum  first,  then  the  semisolid, 
and  lastly  the  soUd  residues  of  food.  Water  leaves  the  atonic 
stomach  with  marked  rapidity,  so  that  the  amount  of  water 
in  the  tissues  of  the  body  is  fairly  constant.  Considering 
the  ease  with  which  the  stomach  empties  itself  of  liquid 
and  semiUquid  foods,  these  should  constitute  a  large  pro- 
portion of  the  diet  in  atonic  states.  The  stomach  can  take 
care  of  large  quantities  of  liciuids  so  long  as  they  are  taken 
regularly  and  in  small  amounts. 

]Milk  holds  first  place  in  the  Ust  of  foods  for  the  dietetic 
treatment  of  gastric  atony.  In  selected  cases  the  milk 
cure,  combined  with  rest  in  bed,  may  be  employed  for  several 
days.  By  administering  at  intervals  of  two  hours  250  to 
300  Cc.  (§viij-x)  of  milk,  2000  Cc.  (2  quarts)  may  be 
taken  during  the  twenty-four  hours  without  producing  over- 
distention of  the  stomach.  In  addition  to  milk,  a  variety 
of  preparations  with  milk  may  be  employed,  as  cocoa,  tea, 
vanilla,  rice,  oatmeal,  and  cornstarch.  Diarrhea,  if  present, 
may  be  checked  by  the  addition  of  lime  water  to  the  milk. 
Schmidt  recommends  to  prevent  fermentation  that  pure 
salicylic  acid,  0.3  Gm.  (5  grains),  be  thoroughly  mixed  with 
a  small  quantity  of  cold  milk,  the  mixture  added  to  the 
daily  quantity  of  milk  (a  liter  and  a  half),  and  the  whole 
boiled.  Sour  milk,  kefir,  and  peptonized  milk  are  useful 
adjuncts  to  the  diet. 


MOTOR   IXSIFFICIESCY  OF   TI/F   FIRST   DEGREE      397 

Diet  in  Normal  Acidity,  Hyperacidity,  and  Hypersecretion. — In  cases 
of  gastric  atony  in  which  the  acidity  is  normal  or  higher 
than  normal,  and  in  hypersecretion,  Strauss  recommends  a 
strictly  protein-fat  diet,  to  obviate  the  carbohydrate  fer- 
mentation which  would  otherwise  result  from  insufficient 
amylolysis.  Since  protein  is  pretty  thoroughly  digested  in 
such  cases,  it  is  not  necessary  that  it  be  taken  in  liquid  or 
semiliquid  form.  Should  gastric  ulcer  or  erosion  be  sus- 
pected, the  nutriment  must  be  liquid.  It  is  necessary  that 
the  protein  food  be  thoroughly  cooked.  An  extensive  variety 
of  meat  and  fowl,  and  dishes  prepared  from  them,  as  well 
as  jellies,  eggs,  and  soft  cheese,  may  be  prescribed. 

Fat,  owing  to  its  power  of  diminishing  secretion,  is  indi- 
cated in  hyperacid  conditions.  Strauss  has  pointed  out  that 
its  use  is  distinctly  advantageous  in  the  treatment  of  atony, 
and  that,  contrary  to  the  view  once  held,  a  fatty  diet 
remains  no  longer  in  the  stomach  than  food  of  other  compo- 
sition. He  does  not  class  it  among  the  so-called  ''heavy" 
foods.  ]\Iotor  insufficiency  with  increased  or  normal  secre- 
tion is  benefited,  and  in  some  cases  a  radical  cure  is  accom- 
plished, by  a  protein-fat  diet.  All  kinds  of  fat  with  a  low 
melting  point  and  pure  in  quality  may  be  employed.  Butter, 
cream,  and  ohve  oil  are  suitable  forms  of  fat;  but  fat  pork 
and  the  fat  of  roast  duck  or  goose  should  be  avoided. 

In  cases  of  well-marked  atony  Strauss  comcmences  treat- 
ment with  an  exclusive  protein-fat  diet,  and  later  adds 
small  quantities  of  carbohydrates  so  that  he  has  a  high 
protein-fat  and  low  carbohydrate  combination.  The  carbo- 
hydrate constituent  consists  of  toast,  zwieback,  biscuits, 
rice,  leguminous  flours  prepared  in  the  form  of  gruels,  soups, 
mashed  potatoes — each  prepared  with  as  large  a  quantity  of 
milk  and  butter  as  can  be  used.  Green  vegetables  should 
be  avoided. 

Diet  in  Subacidity  and  Anacidity. — The  principles  underlying 
the  dietetic  treatment  of  chronic  gastritis  apply  in  this  con- 
dition also.  The  diet  should  be  in  all  cases  liquid  or  semi- 
liquid.  It  should  contain  a  large  admixture  of  fat.  Meats,  if 
eaten,  should  be  taken  in  a  very  finely  subdivided  condition, 


398  MOTOR  IXSUFFICIEXCY 

and  eggs  in  the  form  of  the  light  egg  dishes.  Carbohydrates 
should  be  taken  in  the  form  of  flour  soups  or  leguixiinous 
soups  and  vegetable  purees,  all  of  which  should  be  prepared 
with  as  much  butter  and  milk  as  possible.  Alilk  is  the  best 
beverage  in  this  class  of  cases.  Alcohol  should  not  be  given 
in  gastric  atony  except  in  the  form  of  small  quantities  of 
mild  claret.  Coffee  should  be  interdicted,  and  tea  given 
only  in  combination  with  milk.  After  each  meal  the  patient 
should  rest  in  the  recumbent  position,  preferably  on  the 
right  side.  If  thirst  be  a  troublesome  feature  of  the  disease, 
it  may  be  allayed  by  the  daily  administration  of  two  or 
three  enemata  of  physiologic  salt  solution  of  150  to  200  Cc. 
(^Y-vij)  each,  thus  avoiding  distention  of  the  stomach. 

Lavage  of  the  Stomach. — Lavage  of  the  stomach  is  not  indi- 
cated in  primary  atony,  inasmuch  as  the  stomach  evacuates 
itself  completely  though  perhaps  tardily.  Atony  complicated 
with  hypersecretion  may  be  benefited  by  an  occasional 
lavage.  The  so-called  gastric  douche  has  been  recommended 
in  atony,  and  is  said  to  have  the  effect  of  strengthening  the 
muscular  coats.  Its  value  in  this  condition  is  doubtful. 
When  the  gastric  douche  is  employed  the  rinsing  may  be 
performed  with  the  aid  of  Rosenheim's  tube,  employing 
physiologic  salt  solution  in  subacidity  and  Carlsbad  salt 
solution  in  hjqperacidity ;  the  temperature  of  the  water  may 
be  lowered  gradually  to  54°  F.  Should  the  patient  experience 
loss  of  appetite,  the  washing  process  may  be  accomplished 
with  an  infusion  of  hops  and  quassia  to  which  has  been  added 
a  little  fluidextract  of  condurango  for  its  stimulant  effect 
upon  the  sense  of  hunger.  Riegel  proposes  the  following 
treatment,  which  may  be  termed  a  gymnastic  exercise  of  the 
stomach:  Half  a  liter  of  water  is  permitted  to  flow  into  the 
stomach  through  the  stomach  tube;  the  funnel  or  irrigator 
is  then  removed,  leaving  the  tube  in  position;  the  patient 
then  forces  the  water  out  through  the  tube  by  pressure  on 
the  stomach.  It  is  claimed  that  the  tone  and  motility  of 
the  stomach  have  been  improved  markedly  by  this  method 
of  treatment. 


MOTOR  INSUFFICIENCY  OF  THE  FIRST  DEGREE      399 

Medicinal  Treatment. — The  alkalies  are  indicated  in  cases 
of  atony  accompanied  by  hyperacidity  or  hypersecretion 
as  a  complication.  The  most  suitable  of  these  have  been 
found  to  be  magnesium  oxide  and  the  double  phosphate  of 
ammonia  and  magnesia.  Bicarbonate  of  soda  has  the  dis- 
advantage of  producing,  on  combination  with  the  normal 
acid  secretion,  too  much  carbon  dioxide,  which  causes  over- 
distention  of  the  stomach.  Atropine  is  employed  for  its 
inhibitory  effect  in  cases  of  simple  non-complicated  hyper- 
acidity. Extract  of  belladonna  is  indicated  for  pain. 
Hydrochloric  acid  in  combination  with  pepsin  is  indicated 
in  subacidity  and  anacidity.  In  the  presence  of  fermenta- 
tion such  antifermentative  drugs  as  bismuth,  resorcinol, 
benzol,  salicylic  acid,  and  menthol  are  to  be  employed. 
Strychnine  sulphate,  0.001  to  0.006  Gm.  (^^^j  to  yV  grain), 
hypodermically,  or  extract  of  nux  vomica,  0.008  to  0.05  Gm. 
(I  to  1  grain),  will  increase  the  peristaltic  movements  of 
the  stomach. 

Boas  recommends  the  administration  of  nux  vomica  in 
pill  form : 

Gm.  or  Cc. 

I^ — Extracti  nucis  vomicae 0.1         gr.  iss 

Extracti  gentianse  radicis,  q.  s. 
Misce  et  ft.  pil.  no.  xxx. 
.     Sig. — One  or  two  pills  three  times  a  day,  after  meals. 

Physical  Treatment. — Gastric  atony  of  the  first  degree  has 
been  benefited  by  the  employment  of  hydrotherapeutic 
measures.  Muscular  tonicity  has  been  increased  by  means 
of  the  Scotch  douche  and  cold  compresses  applied  over  the 
gastric  region.  Massage  is  indicated  in  all  cases  of  primary 
atony  uncomplicated  with  dilatation  or  organic  stenosis, 
hyperacidity  or  hypersecretion;  it  may  be  employed  even 
in  ptosis  of  the  stomach.  The  purpose  of  massage  is  to 
improve  the  muscular  tone  and  aid  in  the  expulsion  of  the 
gastric  contents  into  the  duodenum.  When  the  purpose  is 
to  improve  muscular  tonicity,  massage  should  be  undertaken 
when  the  stomach  is  empty;  to  aid  in  emptying  the  stomach 
it  is,  of  course,  performed  when  that  viscus  is  filled  with  food. 


400  MOTOR  INSUFFICIENCY 

Electric  treatment,  consisting  of  intra-  and  extra-ventricular 
faradization,  is  also  emplo^^ed  as  a  means  of  improving  the 
muscular  tone.  Massage  may  be  employed  in  conjunction 
with  electric  treatment,  or  electricity  and  general  massage 
may  be  employed  alternately,  to  be  followed  hy  abdominal 
massage  in  cases  of  arrested  intestinal  peristalsis. 

Treatment  with  Mineral  Waters. — The  use  of  mineral  waters 
has  been  found  advantageous  in  the  treatment  of  very  mild 
cases  of  atony — being  selected  according  to  the  condition 
of  the  gastric  secretion;  in  hj^peracidity  and  in  hypersecre- 
tion the  Carlsbad  waters  and  waters  from  alkaline-acidu- 
lous springs  should  be  employed,  while,  on  the  other  hand, 
sodium  chloride  waters  should  be  used  in  subacidity  and 
anacidity.  The  mineral  water  treatment  should  be  em- 
ployed with  great  caution,  and  the  waters  prescribed  in 
limited  quantities  in  order  to  avoid  overloading  the  stomach. 
Mineral  waters  should  not  be  used  in  these  cases  when  the 
patients  complain  of  more  or  less  severe  symptoms,  but  the 
patients  should  be  sent  to  the  seashore  for  ocean  baths  or 
advised  to  make  climatic  changes. 

In  cases  of  atony  in  which  gastric  ulcer,  gastritis,  ptosis, 
or  neurasthenia  is  known  to  be  present  as  a  positive  factor, 
the  complicating  condition  should  receive  treatment  as 
outlined  in  the  respective  sections  of  this  work. 


MOTOR  INSUFFICIENCY  OF  THE  SECOND  DEGREE 

Motor  insufficiency  of  the  second  degree  is  a  chronic 
condition  in  which  the  stomach  has  lost  entirely  the  ability 
to  expel  its  contents;  that  is,  food  residues  remain  in  the 
stomach  permanently  (stagnation) ;  and  as  a  consequence 
of  this  chronic  condition  of  gastric  insufficiency  we  have 
dilatation  of  the  stomach  (ischochj^nia,  gastrectasis). 

Etiology. — The  cause  of  motor  insufficiencj'  of  the  second 
degree  may  be  either  trauma  of  the  muscle  fibres  of  tlie 
stomach  or  pyloric  stenosis.  It  is  possible  that  primary 
atony  may  in  time  be  transformed  into  motor  insufficiency 


MOTOR  INSUFFICIENCY  OF  THE  SECOND  DEGREE     401 

of  the  second  degree,  with  stagnation  of  the  stomach  con- 
tents. Ciireful  chnical  and  anatomic  examinations  have 
shown  us  that  stenosis  of  the  pylorus  is  the  cause  of  nearly 
ever}'  case  of  motor  insufficiency  of  the  second  degree.  The 
lumen  of  the  pylorus  may  be  narrowed  from  the  inside  or 
from  the  outside;  it  may  be  cicatrized  and  contracted  from 
the  healing  of  gastric  ulcers,  or  there  may  be  cicatricial 
tissue  as  a  result  of  healed  perforations  from  biliary  calculi. 
Spastic  stenosis  of  the  pylorus  is  by  no  means  a  rare  condi- 
tion; it  is  caused  by  the  irritating  effect  of  the  ingesta 
upon  erosion  or  fissure  of  the  pylorus,  or  by  an  abnormally 
high  degree  of  gastric  acidity  (hypersecretion).  This  kind 
of  closure  of  the  pylorus  is  at  first  periodic.  When,  however, 
the  attacks  become  more  frequent,  the  effect  is  permanent 
stenosis.  Spastic  closure  of  the  pylorus  may  also  result 
from  hysterical  crises.  Chronic  hyperplasia  of  the  gastric 
mucous  membrane  {etat  mamelonne)  and  hypertrophy  of 
the  muscles  in  the  region  of  the  pylorus  in  chronic  gastritis 
and  cirrhosis  ventriculi  also  cause  stenosis.  Syphilis  may 
also  become  an  etiologic  factor  in  chronic  hypertrophy  of 
the  pylorus.  Internal  stenosis  resulting  from  malignant 
tumors,  such  as  carcinomata  and  sarcomata,  is  by  no  means 
rare.  Polypi  and  myomata  of  the  pylorus  are  occasionally 
met  with.     Foreign  bodies  may  block  the  pyloric  exit. 

A  valuable  device  for  ascertaining  the  patency  of  the 
pylorus  is  the  Einhorn  duodenal  bucket  (Fig.  5) ;  it  is  very 
similar  to  the  usual  stomach  bucket,  but  much  smaller  in 
size.  It  is  made  of  gold  and  can  be  easily  placed  in  a 
No.  00  capsule.  Fastened  to  a  silk  cord  75  centimeters  long, 
it  is  swallowed  by  the  patient  and  allowed  to  remain  over 
night.  Upon  its  removal  the  contents  are  examined  for 
pancreatic  ferment — which,  if  found,  assures  us  that  the 
bucket  has  passed  through  the  pylorus  and  that  therefore 
the  pylorus  is  patent.  Einhorn  has  also  drawn  attention 
to  an  important  diagnostic  point  in  this  connection :  If  there 
be  an  ulcer  in  the  tract  covered,  the  silk  will  be  discolored 
by  blood,  and  this  will  give  us  a  clue  to  the  site  of  the  ulcer. 

Adhesions  of  the  stomach  to  neighboring  organs  or  to 

26 


402  .1/0  TOR  IX S  UFFICIEXC  Y 

abdominal  tumors  may  cause  pyloric  stenosis  by  compression 
or  by  bending  the  pylorus  upon  itself. 

Symptoms. — As  soon  as  pyloric  stenosis  begins  to  interfere 
with  the  free  passage  of  food  from  the  stomach  to  the 
duodenum,  symptoms  of  greater  or  less  severity  manifest 
themselves.  They  may  at  first  be  the  sjmiptoms  of  motor 
insufficiency  of  the  first  degree,  such  as  pressure  and  a 
sense  of  fulness  after  eating;  and  the  desire  for  food  is 
easily  satiated.  Eventually  the  pressure  sj'mptoms  become 
aggravated  in  proportion  to  the  increasing  stenosis  of  the 
pylorus,  the  stomach  becomes  distended,  and  pain  is  caused 
by  the  incessant  attempt  of  the  gastric  muscles  to  over- 
come the  obstruction  to  the  pyloric  exit.  When  the  obstruc- 
tion becomes  so  pronounced  as  to  effect  a  closure  of  the 
pylorus,  the  food  remains  in  the  stomach  and  stagnation 
results.  Finally  the  stomach  contents  are  expelled  by 
vomiting.  Emesis  increases  in  frequency  and  becomes 
a  troublesome  sj^mptom.  The  appetite,  fair  at  first, 
diminishes  with  the  increasing  stagnation.  Patients  in  the 
meantime  complain  of  severe  thirst.  The  body  becomes 
impoverished  for  fluid,  since  the  stomach  cannot  absorb 
water.  This  condition  is  indicated  by  the  remarkably 
small  quantities  of  urine  excreted  and  by  hard  impacted 
fecal  matter.  The  pyloric  stenosis  is  accompanied  by  pro- 
nounced emaciation.  The  skin  is  dry  and  clammy  because 
of  the  small  amount  of  water  in  the  tissues.  Patients,  as 
a  rule,  complain  of  dizziness,  lassitude,  inability  to  work, 
and  somnolence.  When  the  decomposed  stomach  contents 
pass  into  the  intestine,  pronounced  gaseous  fermentation 
arises,  producing  distention  of  the  bowels,  with  abdominal 
pains  and  headache.  Gastrogenic  diarrhea  may  be  brought 
on  by  the  fermenting  gastric  contents  in  the  bowel. 

Diagnosis. — Dilatation  of  the  stomach  from  stenosis  of 
the  pylorus  may  assume  marked  dimensions.  It  is  a  matter 
of  diagnostic  importance  to  ascertain  the  degree  of  dilata- 
tion. Apart  from  the  anamnesis,  the  diagnosis  is  facili- 
tated by  the  presence  of  abnormal  peristaltic  movements 
(stiffening)  of  the  stomach,  by  the  signs  of  motor  insuffi- 


MOTOR  INSUFFICIENCY  OF  THE  SECOND  DEGREE     403 

ciency  of  the  second  degree,  and  by  examination  of  the 
stomach  contents.  Motor  insufficiency  is  indicated  by  the 
nature  of  the  food  remnants  in  the  stomach  in  the  morning 
after  a  night's  fast.  Fermentation  is  always  present,  its 
extent  depending  upon  the  degree  of  stenosis  of  the  pylorus. 
In  benign  stenosis  the  stomach  contents  are  acid,  owing  to 
the  presence  of  hydrochloric  and  organic  acids,  such  as 
acetic  and  butyric,  the  latter  resulting  from  fermentation; 
sulphuretted  hydrogen  gas  also  is  present,  arising  from  the 
decomposition  of  protein  matter.  In  malignant  stenosis 
(carcinoma),  lactic  acid  predominates,  but  hydrochloric  acid 
may  also  be  present  for  a  considerable  time,  especially  at 
the  beginning  of  the  carcinomatous  process.  The  finding 
of  sarcinse  is  of  diagnostic  significance  in  benign  stenosis  of 
the  pylorus;  the  presence  of  lactic  acid  bacilli  will  aid  in  the 
confirmation  of  malignant  stenosis.  When  the  stagnating 
gastric  contents  become  strongly  acid,  the  urine  may  be 
found  to  be  alkaline  in  reaction,  with  a  resultant  lowering 
of  the  percentage  of  chlorides  in  the  body.  The  presence  of 
bile  in  the  gastric  contents  favors  a  diagnosis  of  stenosis 
of  the  duodenum.  Gastric  hemorrhage  may  occur  in  either 
malignant  or  benign  stenosis  of  the  pylorus. 

Treatment. — The  treatment  of  this  condition  is  essentially 
dietetic.  The  diet  should  be  such  as  to  make  the  least 
possible  demand  upon  the  motor  activity  of  the  stomach. 
It  should  not  be  larger  in  amount  than  is  absolutely  essential, 
and  should  be  ingested  in  a  form  most  easy  of  expulsion 
from  the  stomach  into  the  duodenum.  The  diet  in  this 
class  of  cases  resembles  that  advised  in  atony.  The  condi- 
tion of  the  secretory  function  must  be  carefully  estimated. 
Fat  may  be  prescribed  along  with  protein  when  the  secretion 
of  hydrochloric  acid  is  either  normal  or  above  normal. 
Carbohydrates  I  prescribe  in  as  small  amounts  as  can  be 
got  along  with,  and  give  them  in  the  most  soluble  form 
possible,  preferably  dextrinized.  The  artificial  protein  prep- 
arations are  indicated  in  this  condition.  Green  vegetables 
should  be  avoided,  even  in  the  form  of  purees.  The  food 
should  be  liquid  or  semisolid  in  consistency. 


404  MOTOR  INSUFFICIENCY 

Beverages  should  be  restricted  to  the  lowest  practicable 
luiiit,  and  should  consist  of  drinks  with  a  nutritive  value, 
such  as  milk  or  cocoa.  If  the  patient  can  tolerate  it,  the 
oil  cure  recommended  by  Cohnheim  may  be  employed  with 
advantage.  This  consists  in  the  patient  drinking,  or  in 
having  introduced  by  means  of  the  stomach  tube,  three 
times  a  day,  before  meals,  50  to  60  Cc.  (§iss-ij)  of  pure 
olive  oil,  at  body  temperature.  If  lavage  is  a  part  of  the 
general  treatment,  100  to  200  Cc.  (giij-vj)  of  oil  may  be 
introduced  at  the  conclusion  of  each  lavage,  when  the 
stomach  will  be  sure  to  be  empty.  The  oil  has  an  anti- 
spasmodic action  and  serves  as  a  coating,  being  especially 
useful  if  fissures,  erosions,  or  ulcers  are  present.  Oil  has  the 
additional  advantage  of  diminishing  the  secretion  in  cases 
of  hypersecretion  and  hyperacidity.  The  oil  treatment  is 
recommended  particularly  in  spastic  contraction  of  the 
pylorus. 

When  patients  suffer  much  pain  and  vomit  frequently, 
and  there  are  manifestations  of  marked  fermentative  pro- 
cesses, the  amount  of  solid  and  liquid  food  should  be  mate- 
rially reduced.  In  such  cases  not  more  than  a  liter  (a  quart) 
of  fluid  a  day  should  be  taken  by  mouth.  It  is  sometimes 
necessary  to  resort  to  rectal  feeding.  Whatever  food  is  given 
by  mouth  should  be  in  a  liquid  or  semiUquid  form. 

Rectal  Alimentation.- — The  attempt  should  be  made  to  allay 
thirst,  which  is  often  very  distressing,  by  moistening  the 
lips  and  the  cavity  of  the  mouth.  The  mouth  should  be 
frequently  rinsed  with  cold  aromatic  waters.  Small  pieces 
of  ice  may  be  given,  but  the  water  should  not  be  swallowed. 
When  this  method  of  allajdng  the  thirst  fails,  recourse  must 
be  had  to  rectal  enemata.  Water  is  readily  absorbed  by 
the  rectum  and  colon,  especially  when  the  body  has  become 
much  impoverished  for  want  of  fluids.  Eight  to  ten  ounces 
of  lukewarm  water  should  be  allowed  to  flow  into  the  rectum 
through  a  soft  rubber  tube,  preferably  by  the  droj)  method, 
so  that  the  patient  may  retain  as  nuich  of  the  fluid  as  possi- 
ble until  absorption  takes  place.  Normal  salt  solution  may 
be  used  instead  of  ])ure  water. 


MOTOR  INSUFFICIENCY  OF  THE  SECOND  DEGREE     405 

When  the  quantity  of  urine  for  the  twenty-four  hours  is 
less  than  20  ounces,  Boas  recommends  the  daily  adminis- 
tration of  fluid  enemata  in  such  quantities  as  will  bring  the 
urine  up  to  a  liter  (33  ounces).  When  the  patient  becomes 
very  weak,  analeptics  such  as  sugar  or  whisky  may  be  added 
to  the  enemata.  The  addition  of  alcohol  to  enemata  is 
thought  by  some  authorities  to  aggravate  cases  of  hyper- 
secretion and  hyperacidity,  inasmuch  as  alcohol  absorbed 
from  the  intestine  stimulates  the  secretion  of  hydrochloric 
acid.  When,  however,  the  quantity  is  small,  there  is  little 
occasion  for  fear  that  it  will  excite  gastric  secretion.  In 
addition  to  the  water  clysmata,  the  bouillon-wine  enema  of 
Fleiner  (two  parts  of  bouillon  to  one  of  white  wine  or 
claret)  may  be  given  for  its  stimulating  effect.  Strauss 
recommends  a  mixture  consisting  of  8  ounces  of  water 
or  bouillon,  a  small  quantity  of  sodium  chloride,  half  a 
tablespoonful  of  wine,  and  one  to  two  tablespoonfuls  of 
sugar.  These  enemata  should  be  administered  twice  a  day. 
The  liquid  enemata  are,  as  a  rule,  well  borne  by  the  patient 
for  a  considerable  length  of  time. 

When  it  is  necessary  to  administer  nutrient  enemata,  the 
colon  should  be  thoroughly  cleansed  every  day  by  an  injec- 
tion consisting  of  a  quart  of  water  and  a  teaspoonful  of  salt, 
administered  early  in  the  morning.  Rectal  alimentation 
may  be  given  an  hour  later.  The  nutrient  enema  is  best 
injected  by  means  of  a  fountain  or  Davidson  syringe,  or  a 
plain  hard-rubber  piston  syringe  and  a  soft-rubber  rectal 
tube  which  is  introduced  into  the  anus  from  three  to  five 
inches.  The  injection  (5  to  10  ounces)  should  be  given 
slowly  and  with  very  little  or  no  force,  in  order  to  prevent 
peristalsis,  which  would  result  in  emptying  the  lower  bowel. 
After  the  tube  is  withdrawn  from  the  rectum  the  patient 
should  be  requested  to  lie  quietly  and  to  endeavor  to  retain 
the  enema.  Three  to  five  such  enemata  may  be  admin- 
istered daily.  When  enemata  are  continued  over  a  long 
period  of  time  it  is  advisable  to  wash  out  the  rectum  at 
least  once  a  day  with  warm  water,  soapsuds,  or  boric  acid 
solution;  by  this  means  all  foreign  matter  is  got  rid  of, 


406  MOTOR  INSUFFICIENCY 

feces  dislodged,  and  mucus  and  any  remains  of  former 
injections  washed  away. 

The  large  intestine  is  capable  in  a  high  degree  of  absorb- 
ing nutrient  materials,  but  not  all  articles  of  nourishment 
are  absorbed  equally  well.  Fat  cannot  be  handled  to  good 
advantage  by  the  intestine;  it  should,  therefore,  be  employed 
in  as  small  quantities  as  possible  as  an  ingredient  of  nutrient 
enemata.  It  has  been  demonstrated,  however,  that  the 
large  intestine  can  absorb  fat  with  a  low  melting  point, 
provided  it  is  in  an  emulsified  form.  Even  under  these 
conditions  not  more  than  10  Gm.  (oiiss)  should  be  admin- 
istered during  the  twenty-four  hours.  This  represents  a 
heat  value  of  93  calories.  The  addition  of  pancreatin  to 
fat  is  said  to  aid  its  absorption  somewhat.  The  nutritive 
value  of  milk  in  enemata  consists  chiefly  in  its  carbohydrate 
content. 

The  large  intestine  absorbs  protein  with  much  greater 
facility.  It  is  able  even  to  dispose  of  protein  such  as  egg 
albumin  in  the  natural  state,  especially  when  common  salt 
is  added  to  it.  The  administration  of  egg  enemata  over  a 
long  period  of  time  is  usually  accompanied  by  pronounced 
decomposition,  giving  rise  to  gaseous  fermentation.  Milk 
protein,  such  as  casein,  is  not  so  well  absorbed  as  egg 
protein. 

Some  experimenters  have  attempted  to  peptonize  pro- 
teins in  the  large  intestine  by  adding  pancreatin  to  the 
enemata.  Such  preparations  are,  however,  unsatisfactory, 
and  it  has  been  found  more  advantageous  to  administer 
the  protein  in  the  form  of  peptone.  Albumoses  are  likewise 
absorbed  by  the  rectum  and  colon.  Care  should  be  exercised 
not  to  administer  enemata  in  too  concentrated  a  form  and 
thus  irritate  the  intestine.  Starch,  properly  prepared,  is 
absorbed  entirely,  as  are  also  dextrin  and  sugar.  Sugar 
solutions  in  too  concentrated  form  arc  liable  to  cause  irrita- 
tion of  the  intestine.  The  most  suitable  sugars  are  cane 
and  grape;  it  is  said  that  as  much  as  80  per  cent,  of  the  cane 
and  grape  sugar  administered  in  ]-)ro]ior  solution  per  rectum 


MOTOR  INSUFFICIENCY  OF  THE  SECOND  DEGREE     407 

can  be  appropriated  by  the  body.  Milk  sugar  is  not  so 
easily  absorbed. 

Nutrient  Enemata. — A  large  number  and  variety  of  nutri- 
ent enemata  have  been  devised.  Those  most  commonly 
used  and  shown  bj''  experience  to  be  satisfactory  in  the  treat- 
ment of  pyloric  stenosis  are: 

(a)  The  different  kinds  of  peptones  and  propeptones  in 
the  market  (Armour's,  Carnrick's,  Savory  &  Moore's,  or 
Kemmericli's  peptone,  somatose;  plasmon,  sanose,  nutrose), 
of  which  about  two  or  three  ounces  dissolved  in  six  to  eight 
ounces  of  water  are  injected.  The  different  beef  juices  may 
also  be  diluted  with  water  and  injected  in  corresponding 
quantities. 

(5)  Alilk  and  egg  enemata:  Six  to  seven  ounces  of  milk, 
one  or  two  raw  eggs  well  beaten  up  in  the  milk,  one  teaspoon- 
ful  of  powdered  sugar,  and  one-third  of  a  teaspoonful  of 
common  table  salt.  Pancreatin  (one  tube  of  Fairchild's 
pancreatin)  may  be  added  to  such  an  enema  in  order  to 
facilitate  its  assimilation  (Einhorn). 

(c)  Boas  recommends  8  ounces  of  milk,  two  yolks  of  eggs, 
common  salt,  one  tablespoonful  of  claret,  and  one  teaspoon- 
ful of  flour.  Strauss  modifies  this  enema  by  adding  two 
tablespoonfuls  of  grape  sugar.  If  the  modified  enema  is 
badly  borne,  he  reduces  the  quantity  of  grape  sugar  to  one 
tablespoonful.  In  case  the  odor  is  suggestive  of  acid  fer- 
mentation, he  adds  0.25  Gm.  (4  grains)  of  salicylic  acid 
or  menthol  to  each  enema  as  a  preservative.  In  cases 
where  hyperacidity  and  hypersecretion  are  a  complication, 
wine  is  omitted. 

{d)  The  nutrient  enema  recommended  by  Ewald  consists 
of  40  Gm.  (5x)  of  wheat  flour  stirred  up  in  150  Cc.  (Bv)  of 
tepid  water  or  milk.  To  this  mixture  are  added  one  to  two 
eggs,  3  Gm.  (45  grains)  of  sodium  chloride,  and  50  to  100  Cc. 
(5iss-iij)  of  a  15  to  20  per  cent,  solution  of  grape  sugar;  the 
whole  is  thoroughly  beaten  up.  Claret  may  be  added  as 
required. 

(e)  Riegel's  enema  consists  of  8  ounces  of  milk,  2  to  3 
eggs  with  salt,  and  some  flour. 


408  MOTOR  INSUFFICIENCY 

(/)  For  hospital  practice  Strauss  recommends,  chiefly  on 
the  ground  of  economy:  8  ounces  of  bouillon,  |  ounce  of 
alcohol,  1  ounce  of  grape  sugar,  2  yolks  of  eggs,  ^  teaspoonful 
of  sodium  chloride,  2  to  3  tablespoonfuls  of  gum  Arabic 
mucilage. 

(g)  Leube  employs  enemata  consisting  of  well-chopped 
meat  (5  ounces),  fresh  pancreas  (2  ounces),  and  1  ounce  of 
fat  (butter),  all  thoroughly  mixed  with  about  6  ounces  of 
water. 

(h)  Kussmaul  has  employed  the  following :  Two  to  three 
eggs  beaten  with  an  equal  volume  of  water,  added  gradually 
so  that  a  milky  mass  was  formed.  This  was  left  standing 
for  twelve  hours  in  a  cold  place,  then  heated  to  63°  F.  and 
administered, 

(i)  Moritz  recommends  15  Gm.  (Bss)  grape  sugar,  the 
same  quantity  of  malt  extract,  100  Cc.  (§iij)  milk,  6  Gm. 
(5iss)  common  salt,  1  wineglass  of  claret,  and  2  to  3  eggs. 

(j)  Leube  uses  as  a  peptone  enema  60  parts  of  peptone 
to  300  of  milk. 

(k)  Brandenburg:  Dried  peptone,  20  parts;  grape  sugar, 
20;  sodium  chloride,  1;  the  whole  dissolved  in  200  parts  of 
water. 

(l)  Lattier:  Three  teaspoonfuls  of  dried  peptone,  one 
yolk  of  egg,  125  Cc.  (Siv)  milk,  and  5  Gm.  (75  grains) 
pulverized  starch. 

(m)  Rosenheim:  One  to  two  teaspoonfuls  of  peptone, 
2  of  sodium  chloride,  15  of  grape  sugar;  to  this  add  30 
Gm.  (§j)  of  emulsion  of  pure  cod-liver  oil  in  a  3-per-cent. 
soda  solution.  The  whole  is  to  be  increased  to  250  Cc. 
(§viij)  by  the  addition  of  tepid  water. 

(n)  Mering:  25  parts  peptone  and  25  parts  milk  sugar 
to  200  parts  water;  25  parts  of  alcohol  may  be  added  if 
desired.  Wegele  recommends  dextrinized  food,  such  as 
Nestle's,  instead  of  grape  sugar. 

(o)  Pancreas  enemata:  150  to  200  Gm.  (ov-vj)  hashed 
beef,  60  Gm.  (§ij)  finely  cut  pancreas  substance  (Leube). 

(p)  One-fourth  liter  (l  pint)  of  cream,  25  Gm.  (ovj)  dried 
peptone,  5  Gm.  (75  grains)  pure  pancreatin  (Mering). 


MOTOR  INSUFFICIENCY  OF  THE  SECOND  DEGREE     409 

Klopfer's  prepared  nutrient  enema  is  one  of  the  latest 
preparations  of  this  class  of  food  substances.  It  is  yellowish 
in  color,  consisting  of  small  scales  which  have  only  to  be 
stirred  up  with  warm  water  to  be  ready  for  use.  The  formula 
calls  for  22.5  per  cent,  of  soluble  protein,  73.46  per  cent,  of 
carbohydrates  (starch,  malto-dextrin) ,  and  the  salts  of 
wheat  flour.  The  protein  of  this  enema  is  utilized  only  to 
the  extent  of  19  per  cent.,  while  the  carbohydrates  are 
absorbed  up  to  80  or  90  per  cent.  Klopfer's  enema  does 
not  appear  to  possess  any  distinct  advantages  over  the  egg 
or  peptone  enema;  only  convenience  of  preparation  seems 
to  be  in  its  favor. 

Should  the  patient  experience  difficulty  in  retaining  an 
enema  administered  as  advised  above,  10  drops  of  simple 
tincture  of  opium  may  be  added  to  each  enema.  The  opium 
has  a  quieting  effect  upon  the  lower  bowel,  allaying  any 
local  irritability  that  may  exist.  The  addition  of  opium 
to  the  enema  has  also  been  recommended  for  its  influence 
upon  the  nerve  control  of  thirst. 

Should  it  be  found  necessary  to  act  promptly,  owing  to 
great  deficiency  of  water  in  the  system,  Strauss  advises  the 
rectal  administration,  twice  daily,  of  a  fiter  (quart)  of  water 
containing  50  Gm.  ( §  iss )  of  grape  sugar,  the  same  amount  of 
cream,  a  pinch  of  connnon  salt,  and  25  Gm.  ('5^])  of  soluble 
protein.  The  liquid  should  be  introduced  into  the  lower 
bowel  by  the  drop  method  (proctoclysis).  One  liter  of 
physiologic  salt  solution  may  be  injected  twice  daily  as 
a  thirst  enema. 

When  nutrient  enemata  are  badly  borne,  the  intestine 
should  be  washed  with  a  solution  of  sahcylic  acid,  1  to  1000, 
or  boracic  acid,  1  to  100,  and  the  nutrient  enemata  resumed 
after  two  days. 

In  severe  cases  in  which  no  food  can  be  retained  in  the 
stomach,  rectal  alimentation  may  be  employed  with  advan- 
tage and  continued  exclusively  for  a  period  of  eight  to  four- 
teen days.  The  physiologic  rest  of  the  stomach  afforded 
by  this  method  of  feeding  is  usually  followed  by  marked 
improvement  in  the  gastric  symptoms;  the  improvement  is 


410  MOTOR  IXSUFFICIENCY 

often  so  pronounced  as  to  permit  of  a  resumption  of  feeding 
by  mouth.  Feeding  by  mouth  should,  however,  be  resumed 
very  gradually,  and  as  the  power  of  gastric  digestion  in- 
creases the  number  and  quantity  of  rectal  enemata  may 
be  as  gradually  decreased. 

Subcutaneous  Nutrition.  —  When  rectal  alimentation  fails, 
subcutaneous  nutrition  remains  as  a  last  resort.  It  has 
been  shown  that  grape-sugar  solutions  are  well  borne 
when  administered  h3T)odermically;  the  injection  is,  how- 
ever, accompanied  by  much  pain.  About  100  Cc.  (§iij) 
of  a  10-per-cent.  solution  of  grape  sugar  may  be  intro- 
duced by  means  of  a  cannula  connected  with  a  funnel. 
^^arious  regions  of  the  body  may  be  chosen  for  the  injec- 
tions, as  the  internal  and  external  surfaces  of  the  thighs, 
the  pectoral  muscles,  and  the  h5T)ogastric  region.  Injec- 
tions of  oil,  such  as  ohve  oil  or  oil  of  sesame,  are  said  to 
be  less  painful.  Oil  may  be  injected  in  quantities  up  to 
100  Cc.  by  means  of  a  funnel  and  cannula,  or  the  syringe. 
The  subcutaneous  injection  of  protein  is  very  painful  and 
of  little  or  no  nutritive  value.  Whenever  food  is  injected 
directly  into  the  tissues  the  strictest  asepsis  should  always 
be  observed.  Nutrition  by  hypodermic  injection  is  con- 
sidered only  as  a  last  resort,  and  otherwise  has  very  httle 
in  its  favor.  Subcutaneous  injection  of  water  in  cases  in 
which  the  quantity  of  water  in  the  tissues  has  become 
greatly  reduced  has  been  found  very  efficacious;  the  water 
is  usually  given  as  normal  salt  solution;  from  1  to  1^  liters 
(2  to  3  pints)  may  be  administered,  and  repeated.  In  motor 
insufficiency  of  the  second  degree  accompanied  by  hyper- 
secretion and  vomiting  of  acid  materials  the  body  becomes 
depleted  of  sodium  chloride.  In  such  cases  Strauss  notes 
a  marked  improvement  as  soon  as  the  urine  again  shows 
the  normal  amount  of  sodium  chloride. 

Treatment  by  Lavage. — Routine  washing  of  the  stomach  is 
indicated  in  all  cases  of  motor  insufficiency  in  which  that 
viscus  does  not  completely  empty  itself  of  its  contents  dur- 
ing the  night's  fast.  The  stomach  should  be  emptied  and 
relieved  of  the  retained  food  remnants.     The  most  satis- 


MOTOR  INSUFFICIENCY  OF  THE  SECOND  DEGREE     411 

factory  results  are  obtained  by  the  use  of  gastric  lavage  in 
the  rare  forms  of  atonic  stagnation  with  insufficiency,  and 
in  spastic  stenosis  of  the  pylorus.  After  a  continued  course 
of  gastric  lavage  the  dilated  stomach  has  been  found  to 
approximate  the  normal,  and  the  gastric  muscles  have  shown 
marked  improvement  in  tone;  especially  is  this  the  case  in 
benign  stenosis  of  the  pjdorus.  We  do  not  get  this  improve- 
ment, however,  in  cases  of  malignant  stenosis.  It  is  some- 
times possible,  however,  by  means  of  lavage,  to  arrest  the 
progress  of  pyloric  stenosis.  A  proper  time  for  the  perform- 
ance of  lavage  is  in  the  evening,  before  supper,  so  that  the 
stomach  may  be  relieved  of  undigested  and  decomposed  food 
remnants  before  another  meal  is  taken.  The  clean  stomach 
is  then  in  a  better  position  to  take  care  of  a  moderate  sized 
supper,  with  the  prospect  of  a  minimum  of  gastric  dis- 
turbance as  a  consequence  during  the  night. 

When  there  is  much  gastric  fermentation,  antiseptic  or 
antifermentative  drugs  may  be  dissolved  in  the  water  to 
be  used  for  lavage  purposes.  Among  such  drugs  are: 
Benzoate  of  soda,  which  may  be  used  in  from  1  to  3  per 
cent,  solution:  chloroform  water,  1  per  cent.;  creolin,  10 
to  15  drops  to  a  quart  of  water;  ichthyol,  10  to  20  drops  to 
the  quart. 

Gastric  lavage  is  usually  followed  by  a  marked  ameliora- 
tion of  the  subjective  symptoms.  The  appetite  increases, 
pain  ceases,  vomiting  disappears,  and  thirst  is  diminished, 
while  at  the  same  time  the  urinary  secretion  becomes 
normal  in  amount.  All  this  improvement  should  take 
place  wdthin  three  or  four  weeks,  otherwise  the  prognosis 
for  improvement  is  not  good. 

Instead  of  the  gastric  lavage.  Boas  has  recommended  a 
simple  manual  expression  of  the  gastric  contents  morning 
and  evening  by  the  patient  himself.  Complete  evacuation 
and  cleansing  of  the  stomach  is  not,  however,  attained  by 
this  method. 

When  dilatation  and  ptosis  exist,  improvement  sometimes 
follows  properly  fitting  abdominal  bandages  which  assure 
support  to  the  stomach.    The  reader  is  referred  to  the  chapter 


412  MOTOR  INSUFFICIEXCY 

on  Gastroptosis  for  details  in  regard  to  this  mechanical 
treatment. 

Physical  Treatment. — The  galvanic  current  is  indicated  in 
those  rare  forms  of  motor  insufficiency  of  the  second  degree 
which  are  characterized  by  atonic  insufficienc^^  In  pyloric 
stenosis  the  peristaltic  movements  of  the  stomach  are 
accelerated,  thus  rendering  unnecessary  any  extraneous  aid 
for  the  purpose  of  improving  muscular  tone.  Massage  of 
the  stomach  may  be  practiced  in  the  treatment  of  atonic 
varieties  of  motor  insufficiency  of  the  second  degree.  It 
should  not  be  employed  when  the  stomach  contains  any 
quantity  of  food  remnants,  but  only  after  lavage.  ^Tiatever 
decomposing  material  there  may  be  in  the  stomach  should 
be  completely  removed,  and  not  forced,  as  massage  would 
be  in  danger  of  forcing  it  into  the  intestine.  According  to 
Tabora,  the  stomach  should  be  slightl}^  distended  with  air 
before  effleurage  is  performed. 

Treatment  with  Mineral  Waters. — The  mineral  water  cures, 
so  called,  are  contraindicated  in  motor  insufficiency  of  the 
second  degree  in  the  presence  of  stagnation,  inasmuch  as 
their  employment  would  only  serve  to  increase  the  amount 
of  fluid  in  the  overburdened  stomach.  They  may,  however, 
be  tried,  in  selected  cases,  after  gastric  lavage. 

Medicinal  Treatment. — The  administration  of  drugs  is  prob- 
ably the  least  important  factor  in  the  treatment  of  motor 
insufficiency  with,  stagnation,  inasmuch  as  the  therapeutic 
effect  of  drugs  in  contact  with  decomposed  food  remnants 
in  the  stomach  is  likely  to  be  of  doubtful  value.  Strychnine 
sulphate  may  be  administered  hypodermically.  As  an  anti- 
fermentative  in  cases  of  gastric  distention,  Boas  recommends 
salicylate  of  soda,  1  to  3  Gm.  (15  to  45  grains)  per  day,  and 
salicylate  of  magnesia,  1  to  3  Gm.  (15  to  45  grains)  in  divided 
doses  for  the  twenty-four  hours.  One  cubic  centimeter 
(15  minims)  of  dilute  hydrochloric  acid  ma}'  be  adminis- 
tered several  times  a  day  for  an  extended  period,  in  order 
to  counteract  fermentation  caused  by  the  presence  of  lactic 
and  butyric  acids.  The  vegetable  bitters,  such  as  condu- 
rango  and  quassia,  are  sometimes  useful.     In  spastic  con- 


MOTOR  INSUFFICIENCY  OF  THE  SECOND  DEGREE     413 

traction  of  the  pylorus  brought  on  by  hyperacidity  and 
hypersecretion,  alkalies,  astringents  or  atropine  sulphate 
maj^  be  administered  as  indicated  in  hyperacid  conditions 
of  secretion.  The  latter  drug  should  be  administered  imme- 
diately after  gastric  lavage,  in  order  that  it  may  come  in 
contact  with  the  empty  stomach. 

Fig.  40 


pill  iiiiiniiiiiriTiiiTiiii 


o>       »i 


Einhorn  pyloric  dilator:   A,  rubber  bag  with  gauze  envelope  in  collapsed  shape;  B,  rubber 
bag  with  gauze  envelope  inflated  with  air;   C,  stopcock. 

Treatment  of  Stenosis  of  the  Pylorus. — We  should  direct  our 
treatment  likewise  to  pyloric  stenosis.  Success  is  often  at- 
tained by  combating  the  causes  of  pylorospasm,  which  usually 
consist  of  hyperacidity,  hypersecretion,  or  fissures  and  ulcers 
in  the  region  of  the  pyloric  exit.  This  treatment  may  be  diet- 
etic or  medicinal,  or  it  may  consist  of  lavage  or  the  oil  cure 
already  described  (see  p.  199).  Organic  stenosis  yields  with 
much  greater  difficulty,  if  at  all,  to  internal  medication. 

Einhorn^  has  constructed  a  special  pyloric  dilator  (Fig.  40), 
which  he  has  used  in  a  case  of  congenital  stenosis  of  the 
pylorus  in  an  infant  six  weeks  old  and  in  spasmodic  con- 
traction of  the  pylorus  in  adults.  This  mode  of  treatment 
mil  probably  find  application  in  specially  selected  cases, 
principally  of  pylorospasm  due  to  gastric  ulcer  or  to  remote 
reflexes  (seep.  269). 


1  Illinois  Medical  Journal,  June,  1910. 


414  MOTOR  INSUFFICIENCY 

When  pyloric  stenosis  can  be  traced  to  a  s^'philitic  cause, 
specific  treatment  will  be  productive  of  good  results.  In 
cases  where  the  stenosis  is  due  to  gastric  carcinoma  little 
can  be  hoped  from  a  course  of  internal  medication. 

Some  writers  have  reported  favorable  results  from  the 
administration  of  thiosinamine  or  fibrolysin.  Stuart  reports 
a  case  with  obvious  symptoms  of  pyloric  obstruction  which 
was  greatly  improved  by  the  hypodermic  administration 
of  fibrolysin  in  the  epigastric  region  in  doses  of  2  Cc.  daily 
for  a  month,  every  other  day  for  a  week,  and  thereafter  at 
intervals  of  three  or  four  days  for  three  weeks  more.  The 
patient  became  comfortable  in  a  fortnight.  Stuart  states 
that  one  great  factor  necessary  to  success  in  the  treatment 
of  adhesions  by  fibrolysin  is  that  they  must  be  in  such  a 
location  that  they  can  be  massaged  and  stretched;  other- 
wise, though  they  may  be  rendered  soft,  they  remain  in  the 
same  relation  to  surrounding  tissues  as  before,  and  no  good 
results  can  be  obtained.  Hartz  reports  a  case  of  cicatricial 
stenosis  of  the  pylorus  of  twenty-eight  years'  duration, 
treated  by  thiosinamine  administered  hypodermically,  in 
which  a  perfect  cure  resulted.  Thiosinamine  is  said  to 
possess  the  power  of  softening  cicatricial  tissue,  irrespective 
of  its  origin,  so  as  to  impart  to  it  some  degree  of  elasticity. 
It  has  been  apparently  most  successful  when  employed 
subcutaneously.  The  administration  of  the  drug  in  this 
manner,  however,  presents  difficulties,  since  it  is  necessary 
to  inject  the  drug  in  alcoholic  or  ethereal  solution  because 
of  its  very  slight  solubihty  in  water.  The  injection  is  pain- 
ful. An  aqueous-glycerin  solution  has  been  found  to  be  less 
painful,  but  this  combination  is  unstable. 

Thiosinamine  has  been  superseded  by  the  discover}^  by 
Mendel,  in  1905,  of  an  analogous  preparation,  fibrolysin 
(solution  of  thiosinamine  and  sodium  salicylate),  which  is 
prepared  by  heating  thiosinamine,  sahcyhc  acid,  and  con- 
centrated sodium  hydroxide  in  the  presence  of  free  oxygen. 
The  advantage  of  fibrolysin  consists  in  its  read}'  solubilit}'  in 
cold  water,  so  that  it  may  be  dispensed  in  sterile  solution, 
the  hypodermic  administration  of  which  does  not  cause  dis- 


MOTOR  INSUFFICIENCY  OF  THE  SECOND  DEGREE     415 

tressing  symptoms.  Merck  supplies  fibrolysin  in  brown 
glass  bulbs,  sterile  and  ready  for  use;  each  bulb  or  ampoule 
contains  2.3  Cc.  of  a  solution  of  1|  parts  fibrolysin  to  8§ 
parts  distilled  water;  2.3  Cc.  of  this  solution  corresponds  to 
0.2  Gm.  thiosinamine.  The  effect  of  fibrolysin  is  similar  to 
that  of  thiosinamine,  namely,  the  softening  and  rendering 
elastic  of  cicatricial  tissue,  thereby  preventing  the  contrac- 
tion which  results  from  cicatrix  formation.  This  peculiar 
action  is  attributed  to  the  lymphogenetic  power  of  the 
substance.  In  the  presence  of  pathologically  formed  con- 
nective tissue  it  is  said  to  stimulate  the  formation  of  lymph, 
which  in  turn  produces  serous  infiltration  of  the  cicatrix. 
Disintegration  of  connective  tissue,  as  well  as  immigration  of 
leucocytes  into  the  cicatricial  tissue,  has  been  observed,  so 
that  we  have  as  a  result  a  loose  connective  tissue  rich  in 
cells. 

In  perhaps  the  majority  of  cases,  however,  the  administra- 
tion of  either  of  these  drugs  is  not  of  itself  sufficient  to 
produce  the  effects  described  upon  cicatricial  tissue.  It  is 
necessary  to  employ  massage,  electric  and  hydrothera- 
peutic  treatment  as  well.  The  peristaltic  movements  of 
the  stomach  assist  the  process  in  a  mechanical  way.  As 
already  mentioned,  however,  in  some  cases  the  adminis- 
tration of  fibrolysin  or  thiosinamine  in  cicatricial  stenosis 
of  the  pylorus  is  followed  by  such  an  amelioration  of  symp- 
toms after  several  weeks  or  months  of  treatment  that  the 
patients  have  been  discharged  as  cured.  In  a  few  cases  it 
has  been  possible  to  ascertain  by  means  of  palpation  the 
diminution  of  the  pyloric  obstruction  by  the  gradual  dis- 
appearance of  the  cicatricial  tumor.  A  number  of  cUni- 
cians  have,  however,  been  unable  to  report  any  favorable 
results  whatsoever  from  this  treatment.  I  would  advise 
that  a  trial  be  made  of  these  agents,  especially  in  compara- 
tively vigorous  patients  who  are  able  to  take  and  retain 
nourishment  by  mouth.  In  severe  cases,  however,  in  which 
stenosis  is  well  marked  and  associated  with  emesis  and 
pronounced  emaciation,  such  treatment  will  not  be  suc- 
cessful; to  adopt  it  would  simply  be  temporizing  instead 


416  MOTOR  INSUFFICIENCY 

of  giving  the  patient  the  benefit  of  early  surgical  inter- 
vention. 

Thiosinamine  or  fibrolysin  should  be  injected  in  the 
intrascapular  region;  the  injection  should  be  made  into 
the  muscles;  the  fluid  should  not  be  allowed  to  lodge  in 
the  skin,  owing  to  the  tendency  to  produce  necrosis  there. 
Many  clinicians  claim  that  the  injections  should  be  in  the 
vicinity  of  the  adhesions.  In  pyloric  stenosis,  then,  the 
abdominal  muscles  may  be  selected.  The  gluteal  muscles 
are  likewise  adapted  to  intramuscular  injections. 

Any  untoward  effects  of  thiosinamine  and  fibrolysin  may 
be  obviated  by  interrupting  the  treatment  as  soon  as  a 
peculiar  odor  of  onions  appears  in  the  breath  of  the  patient. 
This  odor  is  due  to  the  excretion  of  ethyl  sulphide.  Head- 
ache, hyperemia,  vertigo,  somnolence,  urticaria,  shght  dis- 
turbances of  sensibility  such  as  paresthesia  and  anesthesia, 
and  fever,  have  been  noted  during  the  administration  of 
these  drugs.  Since  fibrolysin  is  apt  to  produce  more  or 
less  congestion,  some  writers  consider  it  contraindicated 
in  the  presence  of  arteriosclerosis. 

These  remedial  agents  should  not  be  administered  when 
any  active  inflammatory  process  is  present.  The  cornea 
and  conjunctiva  are  said  to  be  particularly  sensitive  to 
the  effects  of  the  drugs.  These  untoward  manifestations, 
however,  are  rarely  observed. 

Should  internal  medication  combined  with  the  treatment 
outlined  fail  after  a  reasonable  time,  the  patient  should  be 
referred  to  the  surgeon.  Gastroenterostomy^  when  per- 
formed early  is  often  followed  b}^  favorable  and  permanent 
results. 

ACUTE  DILATATION  OF  THE   STOMACH 

This  condition  is  noted  especially  after  laparotomies, 
injuries,  chloroform  narcosis,  torsion  of  the  pylorus  or  small 
intestine  or  of  the  mesenter}^,  dietetic  errors,  severe  infec- 
tious diseases,  such  as  pneumonia  and  scarlet  fever,  and 
chronic  exhausting  diseases. 


A  Case  of  Dilatation  of  the  Stoniacli. 

Roentgenogram  taken  immediately  after  laisniuth  subearbonate  was 
given  and  a  coin  placed  over  the  umbilicus.  The  dark  area  shows  the 
stomach    below   tlie   umljilicus. 


PLATE  XXI 


A  Case  of  Dilatation  of  the  Stomach. 

Roentgenogram  was  taken  imnnediately  after  bismuth  subearbonate 
was  given  and  a  coin  placed  over  the  XAmbilieias.  The  stomach  had  begun 
to  contract  toward  the  pyloric  region,  and  for  that  reason  presented  a 
skiagraph  which  might  easily  be  mistaken  for  evidence  of  hour-glass 
stomach. 


ACUTE  DILATATION  OF  THE  STOMACH  417 

When  acute  dilatation  of  the  stomach  takes  place  in  a 
previously  healthy  person  the  clinical  symptoms  are,  as 
a  rule,  most  pronounced.  These  symptoms  consist  of 
vomiting,  intermittent  pains,  collapse,  feeble  pulse,  accel- 
erated respiration,  constipation.  When  the  condition  does 
not  readily  clear  up  it  must  always  be  regarded  as  very 
grave. 

Treatment. — When  a  diagnosis  of  acute  dilatation  has 
been  made,  the  stomach  should  be  emptied  and  lavage 
performed  as  frequently  as  indicated.  No  food  should  be 
given  by  the  mouth;  the  nourishment  should  consist  of 
nutritive  enemata;  otherwise  treatment  should  be  directed 
to  the  reestablishment  of  normal  gastric  peristalsis.  Rectal 
enemata  consisting  of  large  quantities  of  physiologic  salt 
solution  are  indicated.  In  selected  cases  strychnine  sul- 
phate and  atropine  should  be  employed.  Collapse  should 
be  treated  by  means  of  stimulants  and  normal  salt  solution. 
Surgical  intervention  remains  as  a  last  resort. 

In  acute  dilatation  of  the  stomach  following  general  anes- 
thesia, Payer^  makes  a  point  of  having  the  patient  lie  on  the 
right  side  if  there  is  any  tendency  to  vomiting  after  twelve 
to  twenty-four  hours.  This  generally  controls  the  dilata- 
tion, but  if  disturbances  persist  he  gives  a  chamomile  tea 
enema,  with  the  patient  still  lying  on  the  side,  repeating  the 
enema  frequently  at  need,  and  giving  nothing  by  the  mouth. 
In  very  severe  cases  the  knee-chest  position  was  the  only 
means  of  final  relief;  this  never  failed.  He  never  had  to 
resort  to  lavage  of  the  stomach  (see  p.  211  j. 

1  Postnarkotische  Magenlahmung,  Mitteilungen  aus  den  Grenzgebieten  der 
Med.  und  Chir.,  Januarj^  28,  1911. 


27 


CHAPTER  XIX 

GASTRIC  ULCER:  ULCUS  VENTRICULI— ROUND  ULCER- 
PEPTIC  ULCER— PERFORATING  GASTRIC  ULCER 

Gasteic  ulcer  is  a  localized  lesion  of  the  mucous  membrane 
of  the  stomach.  It  is  characterized  by  a  sharp,  well-defined 
outUne,  more  or  less  deep  destruction  of  the  mucosa,  and  by 
no  tendency  to  heal.  The  lesion  gives  rise  to  one  or  more 
characteristic  sjnnptoms^pain,  vomiting,  hematemesis. 
Gastric  ulcer  was  first  described  by  Cruveilhier  in  1829. 

Pathology. — Gastric  ulcer  is  usually  round  or  oval  in  shape. 
In  some  instances  several  ulcers  may  become  confluent  and 
thus  form  a  larger  one  with  an  irregular  border.  Owing  to 
the  tendency  of  the  ulcer,  which  is  at  first  superficial,  to 
penetrate  deeply,  the  base  is  frequently  the  muscular  or 
serous  coat  of  the  stomach.  In  "perforating  ulcer"  the 
base  is  one  of  the  adjacent  viscera,  bound  to  the  stomach  by 
adhesions.  The  ulcer  is  funnel-shaped,  with  the  base  as  the 
apex.  As  a  rule,  ulcers  do  not  attain  a  size  much  larger 
than  a  dime,  though  some  of  the  confluent  variet}^  have 
measured  ten  centimeters  (four  inches)  in  their  greatest 
diameter.  An  ulcer  the  size  of  a  pea  may  exhibit  all  the 
characteristic  symptoms  of  this  pathologic  condition.  The 
typical  gastric  ulcer  has  a  punched-out  appearance. 

In  microscopic  section  of  recent  ulcers  the  margins  show 
the  ducts  of  the  gastric  glands  cut  off  toward  the  base  of 
the  ulcer.  The  erosive  process  may  extend  to  a  point 
where  the  tissues  offer  effective  resistance  to  the  digestive 
power  of  the  gastric  juice  (Einhorn).  In  chronic  ulcers, 
owing  to  a  reactive  inflammation  at  the  periphery,  a  tumor 
of  connective  tissue  is  formed  there,  which  may  be  palpated — 
especially  if  the  ulcer  is  located  near  the  pylorus.  Apart 
from  the  inflammation  surrounding  the  edges  of  the  ulcer, 
the  remainder  of  the  gastric  nnicosa  is  likely  to  be  normal. 


SITUATION  419 

In  the  acute  form  of  the  lesion  the  necrotic  process  may  be 
so  rapid  that  the  thin  serous  coat  is  perforated,  or  a  vessel 
may  be  eroded  so  as  to  occasion  severe  hemorrhage  with  a 
fatal  termination. 

Situation. — The  lesser  curvature  seems  to  be  the  favorite 
seat  of  ulceration.  Welch  collected  793  cases  from  hospital 
records  which  showed  288  to  be  on  the  lesser  curvature, 
255  on  the  posterior  wall,  29  at  the  pylorus,  69  on  the 
anterior  wall,  50  at  the  cardia,  29  at  the  fundus,  27  on  the 
greater  curvature.  According  to  Brinton's  statistics,  in 
43  cases  out  of  100  the  posterior  wall  was  the  location  of 
the  ulcer,  in  27  cases  the  lesser  curvature,  in  16  cases  the 
pylorus,  in  6  cases  both  anterior  and  posterior  surfaces,  in 
4  cases  the  anterior  surface  only,  and  in  2  cases  the  cardiac 
pouch. 

In  about  86  per  cent,  of  cases  the  ulcer  is  situated  on 
the  posterior  surface  at  the  lesser  curvature  and  at  the 
pyloric  sac — parts  of  the  stomach  which  together  form  a 
segment  of  less  than  half  the  total  surface  of  the  viscus. 
This  portion  of  the  stomach  is  subjected  to  the  greatest 
irritation  from  the  moving  mass  of  gastric  contents  which 
a  disturbed  muscular  mechanism  ejects  before  it  is  entirely 
reduced  to  liquid  form  (Barker).  Another  explanation  is 
that  these  parts  of  the  gastric  mucosa  may  be  insufficiently 
nourished,  in  consequence  of  disturbances  of  circulation, 
so  that  they  are  attacked  by  the  digestive  activity  of  the 
normal  gastric  juice,  and  the  so-called  peptic  ulcer  is  the 
result.  Such  disturbances  in  circulation  may  be  caused  by 
severe  trauma,  simple  injury  to  the  stomach,  or  traumatic 
influences  extending  over  a  prolonged  period,  such  as 
pressure  from  corsets,  the  wearing  of  belts  by  workingmen, 
continuous  work  in  a  bent  position,  or  the  tasting  of  super- 
heated dishes  by  cooks.  Insufficient  nourishment,  induced 
by  circulatory  disturbances,  is  also  traceable  to  embolism 
or  thrombosis  of  the  small  arteries  supplying  the  lesser 
curvature  of  the  stomach;  specific  endarteritis;  venous 
stagnation,    from   chronic   inflammatory   processes   of   the 


420  GASTRIC   ULCER 

mucous  membrane;  and  altered  composition  of  the  blood 
(anemia,  chlorosis). 

Frequency. — Lebert  found  one  case  of  gastric  ulcer  in 
200  autopsies.  Griinfeld  places  the  number  at  20  per  cent. 
These  are  the  extremes.  Brinton  found  5  cases  in  100 
autopsies;  Berthold,  one  in  every  37,  or  in  that  proportion. 

Sex  Predisposition  and  Age. — Gastric  and  duodenal  ulcers 
occur  much  more  frequently  in  males  than  in  females 
(Mayo).  They  have  been  observed  at  an  early  age,  Lees 
having  found  perforation  of  the  stomach  in  children  aged 
eight  and  nine  years.  Habershon,  in  an  analysis  of  201 
cases,  noted  the  earliest  age  at  which  gastric  ulcer  occurred 
to  be  ten  years  (the  patient  a  girl) ;  several  children  (girls) 
suffered  from  gastric  hemorrhage  at  fourteen,  others  at 
fifteen  and  sixteen;  the  oldest  patient  was  a  man,  aged 
seventy-one.  This  writer  found  the  disease  in  both  sexes 
to  be  most  frequent  in  the  period  between  twenty  and  fifty 
years.  In  women  the  period  of  liability  was  noted  to  begin 
earlier  than  in  men,  and  to  reach  its  maximum  at  twenty- 
five  to  thirty.  In  men  the  earliest  case  occurred  at  the  age 
of  twenty. 

The  healing  of  deep  ulcers  is  by  cicatrization.  The  scar 
is  pale  and  star-shaped,  with  a  puckering  of  the  surrounding 
mucous  membrane.  Cicatrization  and  scarring  may  event- 
ually lead  to  deformity  of  the  stomach,  producing  the  so- 
called  hour-glass  contraction.  More  often,  however,  there 
is  interference  with  gastric  movement  and  function  by 
adhesions  to  neighboring  organs.  Stenosis  of  the  pylorus, 
with  resultant  obstruction  and  dilatation  of  the  stomach, 
occurs  in  the  healing  of  ulcers  near  the  pyloric  exit.  The 
involvement  of  the  pneumogastric  nerve  in  the  scar  occa- 
sionally gives  rise  to  intense  suffering.  As  stated,  per- 
foration of  the  stomach  wall  by  a  gastric  ulcer  gives  rise 
to  localized  peritonitis,  as  a  result  of  which  the  stomach 
becomes  agglutinated  to  a  neighboi-ing  viscus.  Sometimes 
the  perforation  extends  into  the  adjoining  organ,  resulting 
in  the  formation  of  an  abscess.  Or  we  may  have  fistulous 
connection   with    the   transverse   colon;   this   is   the   most 


SYMPTOMS  421 

common,  though  fistulsae  have  been  recorded  between  the 
stomach  and  the  pleura,  pericardium,  lungs,  gall-bladder, 
and  duodenum.  When  the  anterior  surface  of  the  stomach, 
which  has  no  anatomic  relations  with  other  viscera,  becomes 
the  seat  of  perforation,  so  that  protective  adhesions  may 
not  be  established,  a  general  infective  peritonitis  super- 
venes. The  perforation  or  erosion  of  the  larger  vessels 
produces  hemorrhage  of  greater  or  less  severity,  depending 
upon  the  extent  of  the  injury. 

Symptoms. — The  symptoms  of  gastric  ulcer  are  at  first 
ill-defined,  resembling  those  of  gastritis;  there  is  more 
or  less  discomfort  after  partaking  of  food.  This  is  soon 
followed  by  nausea  and  regurgitation  or  vomiting.  A 
boring  pain  is  characteristic  of  gastric  and  duodenal  ulcer; 
it  comes  on  always  within  an  hour  after  eating,  and  is 
aggravated  by  the  character  of  the  food,  especially  if  the 
latter  be  not  well  masticated.  The  pain  usually  persists 
as  long  as  the  food  remains  in  the  stomach.  The  pain  in 
duodenal  ulcer  appears  at  any  time  from  one  to  three 
hours  after  eating;  it  is  relieved  by  the  taking  of  food. 
Liquid  food  is  borne  much  better  than  solid.  Pain  in  these 
conditions  varies  in  intensity  from  the  slightest  pressure 
discomfort  to  paroxysmal  agony.  The  painful  seizures  are 
particularly  frequent  and  severe  in  gastric  ulcer  complicated 
with  hypersecretion  or  hyperacidity.  The  appetite  is 
usually  good,  but  since  eating  is  followed  by  such  dis- 
tressing symptoms,  patients  are  inclined  to  eat  as  little 
as  possible,  and  consequently  become  much  emaciated  as 
the  condition  progresses. 

The  location  q^  the  pain  corresponds,  as  a  rule,  to  the 
centre  of  the  epigastrium  or  to  the  median  line  of  the  abdo- 
men immediately  below  the  ensiform  appendix.  The  por- 
tion of  the  epigastric  region  to  which  the  pain  is  referred 
forms  a  circular  area  of  less  than  two  inches  in  diameter 
(Einhorn) , 

Cruveilhier  first  described  the  dorsal  pain,  which  appears 
a  few  weeks  or  months  later  than  the  epigastric  pain.  This 
pain,  which  is  of  a  gnawing  character,  is  to  the  left  of  the 


422  GASTRIC   ULCER 

spine  and  at  about  the  eighth  or  ninth  dorsal  vertebra.  It 
may  extend  occasionally  to  the  first  or  second  lumbar  verte- 
bra. Boas  has  drawn  attention  to  a  dorsal  point  of  pressure 
at  the  level  of  the  tenth  to  the  twelfth  dorsal  vertebra,  with 
a  lateral  extension  of  two  to  three  centimeters  and  a  height 
of  one  to  four  centimeters.  This  pressure  point  is  usually 
left  of  the  median  fine. 

The  epigastric  pain  is  increased  on  pressure.  Regarding 
the  inadvisability  of  exerting  much  pressure  in  testing  the 
sensibility  at  this  spot,  Brinton  says:  ''It  is  not  altogether 
superfluous  to  add  another  caution  with  respect  to  the 
pressure  test;  not  only  must  it  be  applied  with  great  care 
and  delicacy  in  the  first  examination  of  a  supposed  case  of 
gastric  ulcer,  but,  as  a  rule,  we  can  scarcely  be  too  reluctant 
to  repeat  it,  even  to  verify  a  presumed  amendment.  At 
any  rate,  its  effects  are  sometimes  so  injurious  that  it  is 
necessary  strictly  to  prohibit  the  patient  from  all  manipu- 
lations of  the  epigastric  region,  as  well  as  from  all  pressure 
produced  by  dress  or  work,  as  with  shoemakers." 

Singer^  calls  particular  attention  to  an  early  sign  of  gastric 
ulcer  which  he  has  found  practically  constant;  this  is  a 
sensation  of  discomfort  or  pain  radiating  from  the  epigas- 
trium toward  the  costal  arches  and  thence  along  the  inter- 
costal nerve  routes  to  the  spine.  The  regularity  of  the 
appearance  of  this  pain  or  sense  of  discomfort,  especially 
in  connection  with  eating,  is  characteristic,  and  almost 
pathognomonic  of  gastric  ulcer,  even  when  there  is  scarcely 
any  dyspeptic  disturbance. 

Vomiting. — Vomiting  usually  occurs  an  hour  or  two  after 
meals,  or  when  the  pain  is  at  its  height;/ and  the  pain  is, 
as  a  rule,  reheved  by  the  emesis.  The  vomitus  consists  of 
either  gastric  juice  or  watery  fluid  containing  partially 
digested  food  remnants.  Instead  of  vomiting,  the  patients 
may  have  attacks  of  nausea. 

Hemorrhage. — Hemorrhage,  if  slight,  may  pass  unno- 
ticed; but  if  there  is  any  considerable  quantity  of  blood 

•  Behandlung  des  runden  Magengeschwiirs,  Medizinische  Klinik,  December 
18,  1910. 


SYMPTOMS  423 

in  the  vomitus  it  will  impart  to  the  latter  a  red  or  coffee- 
brown  appearance.  When  it  is  not  possible  to  detect  the 
presence  of  blood  from  the  macroscopic  appearance  of  the 
vomitus  or  dejecta,  it  is  well,  in  suspicious  cases,  to  resort 
to  Weber's  test.  This  test  is  as  follows:  A  small  portion 
of  the  suspected  material  is  mixed  with  water,  and  this  is 
diluted  with  a  few  cubic  centimeters  of  glacial  acetic  acid 
and  thoroughl}^  shaken  with  ether.  The  ethereal  extract 
has  a  Tokay- wine  color  if  blood  is  present.  If  the  color 
is  not  distinct,  add  to  the  ethereal  extract  equal  parts  of 
freshly  prepared  tincture  of  gaaiacum  and  ozonized  oil  of 
turpentine,  which  mil  produce  a  blue  color  in  the  presence 
of  hemoglobin.  Boas  and  Hartman  advocate  the  examina- 
tion of  both  gastric  contents  and  feces  by  means  of  this 
test  to  detect  concealed  hemorrhages.  The  benzidin  test 
and,  more  recently,  the  phenolphthalein  test  have  been 
devised,  which  give  more  characteristic  reactions  (see  pages 
54  to  57). 

When  gastric  hemorrhage  is  profuse,  the  patient  will 
experience  a  feeling  of  giddiness,  weakness,  syncope,  and 
extreme  thirst.  Among  the  objective  symptoms  is  pallor, 
the  degree  of  which  will  depend  upon  the  amount  of  blood 
lost.  If  the  effusion  of  blood  in  the  stomach  be  considerable, 
hematemesis  or  melena  miay  occur. 

Hematemesis  as  a  symptom  is  not  necessary  to  the  diag- 
nosis of  gastric  ulcer,  though  it  aids  in  confirming  the 
diagnosis.    It  occurs  in  about  half  the  cases  (Habershon). 

Perforation. — Perforation  is  one  of  the  most  frequent 
causes  of  death  from  gastric  ulcer.  The  extravasation  of 
gastric  contents  into  the  peritoneal  cavity  is  attended  by 
sudden  and  severe  abdominal  pain  similar  to  that  brought 
on  by  exertion  or  by  some  dietetic  error.  Syncope  and 
collapse,  weak  running  pulse,  and  peritonitis  with  a  fatal 
termination,  is  the  usual  result  of  perforation  of  a  full 
stomach.  (If  the  stomach  be  empty,  the  symptoms  of 
perforation  are  comparatively  unimportant.)  In  the  event 
of  extravasation  of  gastric  contents  into  the  peritoneal 
cavity,  life  is  saved  only  by  prompt   resort   to  operative 


424  GASTRIC   ULCER 

interference.  In  operations  within  ten  hours  after  per- 
foration the  mortality  is  28  per  cent.;  if  the  operation  be 
delayed  for  more  than  twenty-four  hours,  the  mortality 
rises  to  65  per  cent.;  after  thirty-six  hours,  to  87  per  cent. 
Later,  it  is  practically  hopeless. 

In  perforations  in  which  diffuse  infection  does  not  take 
place,  owing  to  the  fact  that  there  was  no  food  in  the 
stomach,  adhesions  are  formed  with  neighboring  viscera. 
This  subject  is  discussed  under  the  heading  Perigastritis, 
Chapter  XXI. 

According  to  Brinton,  perforation  occurs  in  about  one- 
eighth  of  all  cases  of  gastric  ulcer;  in  female  patients,  he 
says,  about  half  of  the  cases  occur  between  the  ages  of  four- 
teen and  thirty,  and  one-third  in  the  six  years  between 
fourteen  and  twenty,  while  in  the  male  the  distribution  is 
constant  up  to  the  age  of  fifty.  The  average  age  of  those 
subject  to  perforation  is,  in  the  male  forty-two,  in  the 
female  twenty-seven.  The  anterior  wall  of  the  stomach, 
though  rarely  affected  by  ulcer,  is  one  of  the  most  frequent 
sites  of  perforation;  in  all  sites  of  gastric  ulcer  except  this 
the  odds  are  about  sixty  to  one  against  perforation,  whereas 
in  the  anterior  portion  of  the  stomach  they  are  six  to  one 
in  its  favor.  This  region  is  more  exposed  to  external 
pressure  and  motion  and  less  protected  by  adhesions  than 
any  other. 

Appetite. — The  appetite  is  apparently  not  affected  by  the 
presence  of  gastric  ulcer,  though  patients  are  apt  to  eat  but 
sparingly  through  fear  of  the  pain  which  the  act  induces. 
Patients  complain  of  constant  hunger,  owing  to  this  inability 
to  satisfy  the  appetite. 

Complications  and  Sequelae. — Manges,  from  the  viewpoint  of 
origin,  classifies  the  complications  and  sequelae  of  gastric 
ulcer  as  (1)  intragastric;  (2)  extragastric.  Among  the  inti-a- 
gastricare:  (a)  Hemorrhage;  (6)  profound  anemia;  (c)  inter- 
ference with  motihty  of  the  stomach  (if  the  lesion  extends 
deep  into  the  muscularis) ;  (d)  stenoses  of  the  cardia,  pylorus, 
body  of  the  stomach  (hour-glass  contraction);  {e)  gastro- 
succorrhea,  with  its  various  complications,  such  as  tetany; 


DIAGNOSIS  425 

(/)  carcinoma.  The  extragastric  complications  include  (a) 
perforation,  free  and  with  adhesions,  possibly  suppuration, 
also  subphrenic  and  other  abscesses,  fistulse  of  various  kinds; 
(6)  general  emphysema;  (c)  perigastritis,  with  localized 
thickening  of  the  serosa,  adhesions  to  various  organs,  dis- 
placement or  distortion  of  the  stomach.  These  sequelae  are 
dealt  with  in  this  and  other  appropriate  chapters  of  this 
work. 

Diagnosis. — A  probable  diagnosis  of  gastric  ulcer  may  be 
made  from  the  fact  of  profuse  hematemesis,  if  carcinoma  of 
the  stomach  and  hepatic  cirrhosis  can  be  excluded.  Pain 
appearing  shortly  after  eating  and  lasting  for  two  or  three 
hours  is  of  diagnostic  import,  especially  if  there  is  a  circum- 
scribed spot  in  the  epigastric  region  that  is  painful  to  pres- 
sure, or  a  similar  sensitive  area  to  the  left  of  the  eighth 
or  ninth  dorsal  vertebra.  Vomiting  occurring  shortly  after 
meals,  in  patients  who  have  recently  become  pale  and 
anemic,  will  justify  a  probable  diagnosis  of  gastric  ulcer. 
Should  the  vomiting  culminate  in  hematemesis  or  melena, 
and  cause  a  cessation  of  pain,  the  physician  may  reasonably 
conclude  that  the  lesion  is  gastric  ulcer. 

The  following  conditions  may  simulate  gastric  ulcer: 

1.  Superficial  erosion  of  the  stomach.  The  presence  of 
flakes  and  shreds  of  mucous  membrane  in  the  gastric  con- 
tents obtained  by  lavage  will  rule  out  the  possible  presence 
of  gastric  ulcer  (see  p.  477). 

2.  Acute  gastritis.  The  patient's  history  will  often  reveal 
a  cause  for  acute  gastritis  in  the  form  of  unsuitable  or 
irritating  food.  The  hydrochloric  acid  is  either  normal  or 
decreased  in  this  condition;  in  gastric  ulcer  the  acidity  is 
likely  to  be  above  normal. 

3.  Hysterical  or  nervous  vomiting,  with  severe  gastric 
symptoms.  This  class  of  cases  frequently  presents  difficulty 
in  the  matter  of  diagnosis.  Habershon  reminds  us  that  when 
a  patient  is  desperately  ill,  and  the  vomiting  is  so  incessant 
as  to  render  the  outlook  most  grave,  the  prostration  is 
usually  so  great  as  to  prevent  the  bestowal  of  much  care 
or  attention  upon  the  personal  appearance.    If  the  patient 


426  GASTRIC   ULCER 

has  prepared  for  the  medical  visit  by  scrupulous  attention 
to  the  hair  and  the  general  toilet,  some  abatement  must  be 
made  from  the  history  of  the  violent  symptoms. 

4.  Gastric  cancer  maj^  simulate  ulcer.  The  differentia- 
tion may  be  assisted  by  considering  the  age  of  the  patient; 
cancer,  as  a  rule,  is  a  disease  of  middle  and  later  life,  while 
ulcer  usually  occurs  earlier.  If  attacks  of  pain  and  vomit- 
ing have  recurred  from  time  to  time  for  several  years  in  a 
patient  under  middle  age,  the  diagnosis  of  malignancy  is 
very  improbable. 

The  occurrence  of  so-called  bilious  attacks,  always  with- 
out hematemesis,  precludes  the  possibility  of  ulcer  in  a 
complex  of  symptoms  which  might  otherwise  justify  a 
diagnosis  of  either  hepatic  colic  or  gastric  ulcer. 

For  determining  the  location  of  gastric  ulcer,  the  ''thread 
test"  devised  by  Einhorn  has  been  found  valuable.  The 
stomach  being  empty,  the  patient  swallows,  preferably  at 
night,  the  Einhorn  duodenal  bucket  (Fig.  5)  attached  to  a 
braided  silk  thread  that  is  knotted  at  a  point  75  centimeters 
from  the  bucket;  in  swallowing,  this  knot  does  not  enter  the 
mouth,  but  is  held  back  by  the  incisor  teeth.  A  loop  at  the 
upper  end  of  the  thread  is  placed  over  the  ear  to  prevent 
the  upjDer  part  of  the  thread  from  passing  into  the  stomach. 
The  bucket  is  withdrawn  on  the  following  morning  and  the 
thread  examined  for  a  red  or  brown  stain.  The  lower  end 
of  it  is  found  to  be  yellow  or  greenish-yellow,  and  the  bucket 
contains  bile  mixed  with  mucus,  provided  it  has  passed  the 
pylorus — which  it  invariably  does  in  from  two  to  eight 
hours  if  there  is  no  obstruction  such  as  a  contracted  p\'lorus 
and  no  extreme  gastric  relaxation  due  to  atony.  Should 
the  bucket  fail  to  pass  into  the  duodenum,  a  smaller  one 
is  used  the  succeeding  night,  and  in  this  manner  an  approxi- 
mate idea  of  the  calibre  of  the  pylorus  may  be  gained.  By 
measuring  the  distance  from  the  knot  in  the  thread  to  the 
red  or  brown  stain  (should  there  be  one),  we  are  able  to 
definitely  localize  the  ulcer.  If  the  stain  is  39  to  42  centi- 
meters from  the  incisor  teeth,  the  ulcer  is  located  at  the 
cardia;  if  45  to  50  centimeters,  at  the  lesser  curvature;  if 


PROGNOSIS  427 

53  to  56  centimeters,  at  the  pylorus;  and  if  over  60  cen- 
timeters, in  the  duodenum.  From  an  experience  of  100 
cases  in  which  one  to  four  tests  with  the  duodenal  bucket 
were  made,  jXIorgan^  maintains  that  if  this  test  be  made 
several  times  on  one  individual,  and  each  time  a  red  or 
brown  stain  is  found  about  the  same  distance  from  the 
teeth,  a  localized  lesion  of  the  gastric  mucosa  exists,  which 
is  probabl}^  ulcer. 

Prognosis. — With  a  better  understanding  of  the  etiology 
and  pathology  of  gastric  ulcer,  as  well  as  improved  methods 
of  treatment,  the  prognosis  for  complete  recovery  is  much 
more  favorable  than  formerly.  The  reason  there  are  not 
more  successes  in  the  treatment  of  this  pathologic  condi- 
tion is  that  patients  frequently  present  such  indefinite 
symptoms  that  the  nature  of  the  disease  is  obscured  and 
improper  treatment  instituted.  The  further  fact  that  physi- 
cians too  often  fail  to  insist  upon  the  discipUne  necessar}^ 
for  the  accomplishment  of  the  best  results,  but  content 
themselves  with  prescribing  a  few  dietary  rules  and  some 
harmless  drug,  has  resulted  in  a  chronicity  that  at  times 
resists  rational  therapj^  The  physician  should  insist  very 
strongly  on  the  rest  cure.  The  older  the  ulcer  the  more 
unfavorable  the  prognosis.  Peptic  ulcer  having  its  base 
on  the  serous  membrane  or  on  some  organ  in  close  proximity 
to  the  stomach  will  resist  all  medical  treatment;  surgery  is 
the  only  recourse  in  such  cases.  The  location  of  the  ulcer 
is  a  matter  of  importance :  in  ulcers  of  the  pylorus,  owing  to 
the  fact  that  they  tend  to  produce  cicatricial  stenoses, 
sometimes  the  only  hope  for  recovery  lies  in  operative  treat- 
ment. "WTien  the  ulcers  are  deep,  we  are  apt  to  have  such 
complications  as  hemorrhage  from  perforation,  adhesions  to 
the  spleen  if  the  ulcer  happens  to  be  located  in  the  fundus, 
and  perigastritis.  With  hypersecretion  as  an  accompani- 
ment the  prognosis  for  complete  recovery  from  gastric  ulcer 
is  less  favorable  than  in  a  case  of  simple  hyperacidity. 

^  William  Gerry  Morgan,  The  Diagnosis  and  the  Feeding  in  Gastric  Ulcer, 
Medical  Record,  March  4,  1911,  p.  381. 


428  GASTRIC  ULCER 


TREATMENT 

Prophylaxis. — A  properly  selected  diet  will  do  much  to 
prevent  the  occurrence  of  ulcer  of  the  stomach.  An  absolute 
milk  diet  should  be  prescribed  as  soon  as  the  first  symptoms 
of  the  disease  become  manifest.  Care  should  be  exercised 
to  avoid  extremes  of  temperature  in  food.  An  effort  should 
be  made  to  overcome  the  hyperchlorhydria  which  is  an 
important  etiologic  factor  in  gastric  ulcer.  The  anemia 
which  is  a  frequent  accompaniment  of  the  disease  should 
likewise  be  treated. 

Leube-Ziemssen  Treatment. — A  therapeutic  procedure  suit- 
able to  slight  or  moderately  severe  cases  of  gastric  ulcer 
uncomphcated  by  hemorrhage  is  the  Leube-Ziemssen  treat- 
ment. After  the  diagnosis  has  been  confirmed,  the  patient 
is  given,  for  the  first  fourteen  days,  complete  rest  in  bed. 
Every  morning,  an  hour  before  partaking  of  food,  he  is 
given  one-quarter  liter  (2  pint)  of  Carlsbad  Muhlbrunnen  (at 
90°  F.)  in  which  is  dissolved  5  to  10  Gm.  (75  to  150  grains)  of 
natural  or  artificial  Carlsbad  salts.  It  is  also  advisable  to  dis- 
solve 10  grammes  of  Carlsbad  salt  in  a  quarter  of  a  Hter  of 
pure  water  at  a  temperature  of  90°F.,  to  be  sipped  at  intervals. 

Hot  fomentations  should  be  apphed  over  the  epigastrium 
during  the  day.  For  this  purpose  mashed  potato  poultices 
or  linseed  poultices  are  good;  or  a  felt  sponge  cut  to  proper 
size  and  dipped  in  hot  water,  as  suggested  by  Boas,  may  be 
employed.  In  using  thermophores,  which  furnish  a  con- 
tinuous even  temperature,  care  should  be  exercised  to  avoid 
pressure  on  the  stomach.  A  piece  of  clean  flannel  cloth 
should  be  interposed  between  the  skin  and  the  poultices. 
During  the  night  a  moist  Priessnitz  bandage  may  be  em- 
ployed with  advantage. 

The  diet  for  the  first  ten  to  fourteen  days  should  consist 
chiefly  of  milk,  neither  hot  nor  cold.  During  the  first  two 
or  three  days  of  the  fourteen,  a  quarter  of  a  liter  (2  pint) 
of  milk  should  be  given  per  day  in  tablespoonful  doses  at 
regular  intervals.    This  quantity  is  then  gradually  increased 


LEUBE-ZIEMSSEN  TREATMENT  429 

to  one-half  liter,  and  at  the  end  of  the  first  week's  treatment 
to  one  liter.  The  calorific  value  of  this  small  quantity  of 
milk  may  he  enhanced  by  the  addition  of  cream ;  the  increase 
in  calorific  value  can  be  estimated  from  the  following  calcu- 
lation by  Strauss: 

Calories. 

A     100  Gm.  full  milk 70 

B       75  Gm.  full  milk  +  25  Gm.  cream 115 

C      50  Gm.  full  milk  +  50  Gm.  cream 185 

D      25  Gm.  full  milk  +  75  Gm.  cream 205 

E     100  Gm.  cream 250 

Therefore  there  are  present  in  one-half  liter  (1  pint)  of  each 
of  these — milk,  milk  and  cream,  and  cream — the  following: 

Calories. 

A 350 

B 575 

C 925 

D 1025 

E 1250 

Yolk  of  egg  may  be  added  to  the  milk.  When  milk  is 
ill-borne  or  patients  exhibit  a  dislike  for  it,  it  may  be  made 
more  palatable  b}'^  the  addition  of  tea,  cocoa,  vanilla,  or 
milk  rice  and  milk  jellies.  Beaten  cream  or  cream  jellies 
may  be  given.  Milk  soups  with  rice,  oatmeal,  or  the  infant 
flours  (half  a  tablespoonful  of  flour  to  half  a  pint  of  milk) 
will  be  found  agreeable  to  most  patients.  Sugar  may  be 
added  to  suit  the  taste. 

When  aversion  to  milk  is  very  pronounced,  Strauss  does 
not  insist  on  its  use.  In  such  cases  the  most  suitable  sub- 
stitute for  the  first  days  of  treatment  is  yolk  of  egg  beaten 
up  with  sugar  so  that  the  patient  takes  two  to  four  eggs 
per  day;  or  flour  soups  with  the  addition  of  butter  may  be 
employed. 

When  the  quantity  of  food  taken  is  too  small,  on  account 
of  severe  pain,  it  is  advisable  to  add  to  the  soups  such 
concentrated  foods  as  sanatogen,  plasmon,  or  fluid  somatose. 
Jellies  made  from  chicken,  meat,  or  raspberries  may  be 
employed  with  advantage.    Patients  who  are  fond  of  sweets 


430  GASTRIC   ULCER 

should  be  given  syrupy  fruit  juices,  such  as  are  made  from 
apples  or  raspberries;  or  malt  extract  may  be  added  to  the 
milk  or  cocoa. 

Leube  recommends  for  the  first  week's  treatment  bouillon 
in  the  form  of  Leube-Rosenthal's  meat  solution.  I  do  not, 
however,  consider  it  ad\asable,  especially  in  the  first  period 
of  treatment,  to  subject  the  gastric  mucosa  to  the  irritation 
which  attends  the  ingestion  of  meat  extractives.  ]Meat 
extracts,  if  used  at  all,  should  be  prescribed  for  weak  patients 
only,  as  analeptic  agents,  and  should  be  given  without 
condiments. 

This  strict  diet,  as  outhned,  should  be  continued  for  at 
least  ten  days.  If  the  pains  subside  rapidly  the  diet  may  be 
increased.  WTien,  however,  the  pain  persists,  it  is  necessary 
to  prolong  the  period  of  physiologic  rest  to  fourteen  days. 

As  might  be  expected,  patients  on  such  a  regimen  decrease 
in  weight.  The  loss  of  weight,  howeA'er,  may  be  accepted 
calmly,  since  the  meagre  diet  has  contributed  to  the  comfort 
of  the  patient  and  shielded  the  gastric  mucosa  from  undue 
irritation. 

Near  the  end  of  the  second  week,  if  the  patient's  condi- 
tion permit,  bouillon  or  soups  enriched  with  yolk  of  egg, 
breast  of  chicken,  or  squab,  enter  into  the  dietary.  The  flour 
soups  mentioned  may  be  continued.  WTien  the  pains  have 
wholly  disappeared  a  careful  trial  may  be  made  of  a  few 
teaspoonfuls  of  very  finely  chopped  breast  of  chicken  or 
squab.  If  this  be  easily  borne,  fight  egg  dishes  are  added  to 
the  dietary.  Then,  tentatively,  a  few  dessertspoonfuls  of 
mashed  potatoes,  softened  biscuits  (crackers),  or  zwieback 
may  be  administered.  Owing  to  the  preponderance  of 
Hquid  nourishment,  patients  do  not  experience  much  thirst 
during  the  first  and  second  periods  of  the  treatment;  thirst 
may  be  allayed  bj^  small  pieces  of  ice  dissolved  in  the  mouth. 
The  white  of  an  egg  mixed  with  200  Cc.  (5vij)  of  water  to 
which  a  teaspoonful  of  sugar  is  added  is  recommended  as  a 
beverage.  Small  quantities  of  carbonated  waters  containing 
a  low  percentage  of  carbon  dioxide  may  be  permitted. 

The  diet  during  the  second  period  should  be  maintained 


LEUBE-ZIEMSSEN  TREATMENT  431 

until  the  end  of  the  third  week,  during  which  time  the  patient 
should  be  kept  at  rest  in  bed.  Carlsbad  water  is  continued, 
likewise  the  hot  applications  over  the  epigastrium.  At  the 
end  of  three  weeks  the  patient  may  be  placed  upon  a  more 
extended  diet.  Strauss  permits  such  article  of  foods  as 
light  cheese,  boiled  chicken,  squab,  small  steak,  brain  and 
sweetbreads,  minced  veal  cutlets,  and  boiled  calf's-feet. 
Ham  and  uncooked  meat  should  be  avoided.  At  this  period 
of  the  treatment,  fish,  such  as  pike  or  trout,  well  cooked  and 
served  with  butter  balls  and  butter  sauce,  may  be  intro- 
duced; also  mashed  potatoes,  as  well  as  other  kinds  of  vege- 
tables in  the  form  of  purees.  The  quantity  of  biscuits  and 
zwieback  may  be  increased,  care  being  exercised  that  such 
articles  are  completely  broken  up  and  taken  in  a  soft,  moist 
condition.    The  milk  diet  is  meanwhile  continued. 

This  dietetic  treatment  is  employed  up  to  the  fourth  week. 
The  hot  fomentations  need  not  be  resorted  to  so  frequently 
during  the  fourth  week.  During  the  latter  part  of  this  period 
the  patient  is  allowed  to  get  up  and  thfe  hot  applications 
are  discontinued.  The  diet  is  arranged  on  an  increasingly 
liberal  basis.  Such  foods  as  biscuits,  zwieback  and  white 
bread  toast  should  be  carefully  masticated.  The  regular 
diet  to  which  the  patient  has  been  accustomed  should  not 
be  resumed  under  two  months  from  the  initial  treatment. 

Summary  of  Leuhe  Treatment. — There  are  four  cardinal 
points  to  be  observed: 

1.  Rest  in  bed  from  one  to  two  weeks.  This  relieves  the 
pain  and  promotes  healing.  After  the  tenth  day  the  patients 
he  down  two  hours  after  dinner. 

2.  Carlsbad  water,  a  quarter-liter  (half  pint),  lukewarm. 

3.  Application  of  a  hot  poultice  or  thermophore  to  the 
epigastrium.  The  poultice  must  be  changed  every  fifteen 
minutes  and  kept  very  hot.  Leube  never  uses  poultices  in 
the  case  of  bleeding  ulcers,  as  they  are  apt  to  cause  a  recur- 
rence of  the  hemorrhage.  During  hemorrhage  ice  bags 
are  used  instead. 

4.  Light  diet  of  high  nutritive  value  and  ready  digesti- 
bility. 


432  GASTRIC   ULCER 

All  four  of  these  factors  must  be  carried  out.  B3'  this 
routine  Leube  claims  he  has  reduced  his  mortality  from 
13  per  cent,  to  2.5  per  cent.,  and  finally  to  barely  0.5  per 
cent.  In  severe  hemorrhagic  cases  he  puts  the  patients  to 
bed,  gives  one  dose  of  30  minims  of  a  1-to-lOOO  solution  of 
suprarenal  extract,  places  an  ice  bag  on  the  abdomen,  and 
quiets  the  stomach  mth  bismuth  and  a  hypodermic  injec- 
tion of  morphine.  He  does  not  beheve  in  giving  eggs  and 
milk  to  bind  the  acid;  he  says  it  causes  the  secretion  of 
more  acid  and  induces  peristalsis. 

He  reports  the  following  results:  In  547  non-hemorrhagic 
cases,  90  per  cent,  cured,  most  of  these  in  four  to  five  weeks; 
no  deaths.  In  hemorrhagic  cases,  90  per  cent,  cured;  2.5 
per  cent,  fatal.  For  the  first  few  days  after  a  hemorrhage 
he  gives  no  food  whatever  by  mouth. 


EiXHORx's  Modification  of  Leube-Ziemssex  Diet — ^Outlixe  of  Diet 
IX  Gastric  Ulcer 

First  Three  Days 

No.  of  calories. 

7  A.M.     Milk,  150  Cc.  (5  ounces) 101 

8  A.M.     Milk,  150  Cc 101 

9  A.M.     Milk,  150  Cc 101 

10  A.M.     Milk  with  strained  barley  water,  1.50  Cc.       ...         80 

11  A.M.     Milk.  1.50  Cc 101 

12  M.        Milk,  150  Cc 101 

1  P.M.     Bouillon,  either  alone  or  with  the  addition  of  one  or 

two  teaspoonfuls  of  a  peptone  preparation,  150  Cc.        30 

2  P.M.     Milk,  150  Cc 101 

.3  P.M.     Milk,  1.50  Cc 101 

4  P.M.     Milk,  150  Cc 101 

5  P.M.     Milk  with  strained  barley  or  oatmeal,  150  Cc.  SO 
6,  7,  SandOp.M     Milk,  1.50  Cc 404 

1402 


1 

A..M 

9 

A.M 

11 

A.M. 

1 

P.M. 

3 

P.M. 

5  P.M. 

7 

P.M. 

9 

P.M. 

V 

A.M. 

9 

A.M, 

11 

A.M. 

1 

P.M. 

3 

P.M. 

5 

P.M. 

7 

P.M. 

9 

P.M. 

LEUBE-ZIEMSSEN   TREATMENT  433 

Fourth  to  Tenth  Day 

No.  of  calories. 

.Milk,  300  Cc 202 

Milk,  300  Cc 202 

Milk  with  barley,  rice,  or  oatmeal  water,  300  Cc.     .  IGO 
One  cup  of  bouillon,  200  Cc,  and  one  egg  beaten  up 

in  it 80 

Milk,  300  Cc 202 

Milk,  300  Cc 202 

Milk  with  barley  water,  300  Cc 160 

Milk,  300  Cc 202 

1410 
Eleventh  to  Fourteenth  Day 

No.  of  calories. 

Milk,  300  Cc 202 

Milk,  300  Cc,  and  two  softened  crackers  (1  ounce)  302 

Milk  with  barley  water,  300  Cc 160 

One  cup   of  bouillon,   200  Cc,   one  egg  and   two 

crackers 180 

Milk,  300  Cc,  and  one  egg 282 

Milk,  300  Cc,  and  two  crackers 302 

Milk  with  barley  water,  300  Cc 160 

Milk,  300  Cc 202 

1790 
Fourteenth  to  Seventeenth  Day 

No.  of  calories. 

Milk,  300  Cc 202 

Milk,  300  Cc,  and  two  crackers 302 

Milk  with  barley,  300  Cc 342 

Scraped  meat,  50  Gm.,  two  crackers,  one  cup  of 

bouillon  (200  Cc.) 160 

Milk,  300  Cc 202 

Milk,  300  Cc,  one  egg  (soft-boiled),  two  crackers  382 

Milk  with  farina,  300  Cc 342 

Milk,  300  Cc 202 

2134 
Seventeenth  to  Twenty- fourth  Day 

No.  of  calories. 

7  A.M.     Two  eggs   (soft-boiled);   butter,   10  Gm.;  toasted 

bread,  50  Gm.;  milk,  300  Cc 573 

10  A.M.  Milk,  300  Cc;  crackers,  50  Gm.;  butter,  20  Gm.  .  530 
1  P.M.     Lamb  chops  (broiled),  50  Gm.;  mashed  potatoes, 

50  Gm.;  toasted  bread,  50  Gm 234 

4  P.M.     The  same  as  at  10  a.m 530 

6.30  p.m.  Milk    wdth    farina,    300    Cc;     crackers,    50    Gm.; 

butter,  20  Gm 670 

9  P.M.     Milk,  300  Cc;  butter,  10  Gm.;  one  cup  bouillon, 

200  Cc 283 


7 

a.m. 

9 

A.M. 

1 

A.M. 

1 

P.M. 

3 

P.M. 

5 

P.M. 

7 

P.M. 

9 

P.M. 

28 


2820 


434  GASTRIC   ULCER 

Persons  subject  to  ulcer  should  lead  abstemious  lives  in 
regard  to  diet  and  beverages,  and  those  who  have  been 
cured  should  not  undertake  heavy  work  or  violent  exercise 
within  a  year  from  the  cessation  of  the  sj'mptoms. 

Riegel  advises  confining  the  patient  to  bed,  with  rectal 
alimentation,  for  several  daj's  before  beginning  the  Leube 
treatment .  The  reasonableness  of  this  procedure  is  apparent, 
since  absolute  rest  brings  about  a  cessation  of  pain  and 
vomiting  and  facilitates  the  healing  of  the  ulcer.  In 
cases  in  which  the  Leube  method  of  treatment  may  be 
unsatisfactorv',  Boas  recommends  for  the  first  eight  or  ten 
daj^s  an  ''abstinence  cure,"  which  consists  in  keeping  the 
patient  in  bed  and  feeding  him  by  rectum  three  or  four 
times  a  day.  Small  pieces  of  ice  or  small  quantities  of  acidu- 
lous mineral  waters  are  allowed  to  allay  thirst.  Suitable 
enemata  ma}'  be  made  of  milk,  five  ounces,  with  one  beaten- 
up  egg  and  one  teaspoonful  of  Fairchild's  peptonizing 
powder.  This  should  be  alternated  with  six  ounces  of  con- 
centrated beef  tea  or  of  meat  essence.  Liquor  pancreaticus, 
N.  F.,  may  be  added  to  the  enema  (see  p.  178).  In  a  large 
patient  the  size  of  the  enema  should  be  increased  to  eight 
ounces.  AMien  the  patient's  strength  flags,  two  teaspoonfuls 
of  whisky  should  be  added  to  the  enema  ('increased  if  neces- 
sary to  a  tablespoonful).  In  every  case  the  bowel  must  be 
washed  out  once  daily  wdth  an  injection  of  about  one-half 
pint  of  warm  soapy  water;  or  an  enema  of  four  ounces  of 
olive  oil  may  be  given  if  the  patient  is  constipated. 

By  regulating  the  diet  it  is  possible  to  protect  the  ulcer 
from  mechanical  injury  and  to  arrest  further  progress  of 
the  ulcerative  process. 

Lenhaxtz  Treatment. — Among  the  more  recent  methods  of 
treatment  of  gastric  ulcer,  especially  when  complicated 
with  hemorrhage,  is  that  devised  by  Lenhartz.  The  prin- 
ciple underlying  this  treatment  involves  the  maintenance  of 
enforced  nutrition  from  the  beginning,  that  is,  from  the 
time  of  the  hemorrhage.  Lenhartz  administers  the  minimum 
quantity  of  food  with  maximum  calorific  value.  He  argues 
that  in  the  Leube  treatment  the  nutrition  of  the  patient  is 


LEX II ART Z   TREATMENT  435 

SO  far  below  his  needs  that  the  anemic  condition  is  bound 
to  become  more  pronounced  and  the  chances  for  the  ulcer 
to  heal  are  greatly  lessened,  Lenhartz  by  his  protein  regimen 
aims  to  counteract  the  hyperacidity  so  frequently  present 
in  gastric  ulcer.  Strong  emphasis  is  placed  upon  the  im- 
portance of  physical  rather  than  physiological  rest  of  the 
stomach. 

The  Lenhartz  method  of  treatment  is  as  follows:  Absolute 
rest  in  bed  for  at  least  four  weeks.  All  mental  excitement 
must  be  avoided.  An  ice  bag  is  placed  over  the  region  of 
the  stomach  and  kept  there  almost  continually  for  two  weeks; 
this  prevents  gaseous  distention  and  promotes  contraction 
of  the  walls;  it  also  obviates  hemorrhage,  and  eases  the 
pain  when  pain  is  present.  On  the  first  day,  even  when 
•hematemesis  has  occurred,  the  patient  receives  between  200 
and  300  Cc.  (§vij-x)  of  iced  milk,  in  teaspoonful  doses,  and 
from  two  to  four  beaten  raw  eggs — within  the  first  twenty- 
four  hours.  At  the  same  time  bismuth  subnitrate  is  given 
twice  or  three  times  a  day,  2  Gm.  ^30  grains)  at  a  dose, 
and  continued  for  ten  days.  The  eggs  are  beaten  up  entire 
(with  a  little  sugar),  and  the  cup  containing  them  is  placed 
in  a  dish  filled  with  ice,  so  that  they  remain  cold.  This  food 
at  once  "binds"  the  supersecreted  acid  and  therefore 
rapidly  mitigates  the  pain;  and  the  vomiting,  which  is 
often  quite  troublesome,  ceases.  The  portion  of  milk  is 
increased  each  day  by  100  Cc.  (5iij);  and  one  additional 
egg  is  given,  so  that  at  the  end  of  the  first  week  the  patient 
is  receiving  800  Cc.  (1^  pints)  of  milk  and  from  six  to  eight 
eggs.  Both  these  foods  are  continued  in  the  same  amount  per 
diem  for  another  week.  No  more  than  a  Hter  (quart)  of  milk 
a  daj^  is  allowed  at  any  time.  Besides  milk  and  eggs,  some 
raw  chopped  meat  is  given  between  the  fourth  and  the  eighth 
day,  usually  on  the  sixth — 35  Gm.  (3ix)  in  small  divided 
doses  (stirred  up  with  the  eggs  or  given  alone);  the  day 
after,  70  Gm.  (5xviij);  and  later  possibly  more  if  the  pre- 
vious portions  have  been  well  digested.  The  patient  is  now 
able  to  take  some  rice,  well  cooked,  and  a  few  zwiebacks 


436 


GASTRIC   ULCER 


(softened).    During  the  third  week  a  mixed  diet  is  tolerated, 
the  meat  being  given  well  cooked  or  lightly  broiled. 

Among  the  advantages  of  the  Lenhartz  method  of  treat- 
ing gastric  ulcer  are :  The  avoidance  of  an  abstinence  period, 
so  distressing  to  many  patients;  the  prevention  of  loss  of 
weight;  and  the  rapidity  with  which  the  hemoglobin  attains 
the  normal  after  hemorrhage  of  greater  or  less  severity. 
On  the  eighth  day  after  a  hemorrhage  Lenhartz  sometimes 
prescribes,  in  addition  to  bismuth,  Blaud's  iron  pills  in 
finely  powdered  form. 


Diet  in  Ulcer  op  the  Stomach  (Lenhartz) 


Days  after  hemorrhage 


Eggs 

Milk  (Cc.)   .... 
Sugar  to  the  egg  (Gm.) 
Raw  beef  (Gm.) 
Milk  rice  (ground  rice)  (Gm.) 
Zw-iebaok  (Gm.) 
Raw  ham  (Gm.)     . 
Butter  (Gm.)    .      .      . 
Calories       .... 


1 

2 

3   4 

5 

6 

7 

8  j  9 

10 

11 

12 

13 

2 

3 

4   5 

6 

7 

8 

8   8 

8 

8 

8 

8 

200 

300 

400  500 

600 

700 

800 

900  1000 

1000  1000 

1000 

1000 

20  20 

30 

30 

40 

40   50 

50   50 

50 

50 

35 

2x35 

2x35  2x35 

2x35  2x35 

2x35 

2x35 

100 

100  200 
20   40 

200 
40 
50 

300 
60 
50 

300 
60 
50 

300 
SO 
50 

20  j  40 

40 

40 

280 

420 

637  777 

955 

1135 

1588 

1721  2138 

2478 

2941 

2941 

3007 

14 


1000 

50 

2x35 

400 

100 

50 

40 


Eisner  has  modified  the  Lenhartz  treatment  by  adminis- 
tering on  the  first  day  of  the  hemorrhage  a  decoction  of 
hygiama  (see  p.  114)  prepared  with  milk  and  a  small  quan- 
tity of  sugar  and  kept  on  ice.  This  constitutes  the  diet  for 
the  first  five  days.  Beginning  with  the  sixth  day,  butter, 
cream,  softened  zwiebacks,  and  eggs  are  added.  To  render 
the  acidity  neutral,  Eisner  administers  soda  bicarbonate  in 
teaspoonful  doses  three  times  a  day.  Duration  of  treatment, 
four  to  six  weeks. 

Senator  administers  as  nourishment  gluten  and  gelatin 
to  neutralize  the  hyperacidity  and  to  promote  hemostasis: 


I^ — Decoctinis  gelatiiii. 

Oleosacchara;  limoni.s  . 
Misce. 
Sin. — To  he  waniicfl  before  u.se. 


ad 


Gm.  or  Cc 
50.0  to  4o().0     5iss-xv 
500.0     Oj 


EINHORN'S   1)1  -ODKSAL   ALI MENTATIOX 


437 


In  the  presence  of  marked  hemorrhage  5  Cc.  of  a  1  to 
1000  adrenahn  sohition  may  be  added  to  this  mixture. 
In  severe  cases  tablespoonful  doses  are  to  be  administered 
at  quarter-  to  half-hour  intervals;  in  Ughter  cases,  the  same 
quantity  at  three-hour  intervals.  Liquid  diet,  consisting 
of  milk,  milk  of  almonds,  cream,  thin  gruel  soups,  butter 
(30  Gm.  in  twenty-four  hours),  fresh  eggs  cooled  on  ice, 
and  small  lumps  of  ice,  is  administered  from  the  commence- 
ment of  the  treatment.  Cream  may  be  supplied  as  whipped 
cream,  ice  cold,  with  or  without  sugar.  Senator  prescribes 
this  diet,  in  amount  1000  calories,  immediately  after  the 
hemorrhage.  The  number  of  calories  may  be  rapidly  raised 
by  the  addition  of  milk  and  eggs. 

Constipation  is  met  by  enemata  of  warm  water  to  which 
soap,  glycerin,  olive  oil,  or  chamomile  tea  may  be  added. 


Fig.  41 


M 

1        '''"'■"■■ 

0 
^ 

f 

u      [ 

O" 


Einhorn  duodenal  pump:  A,  metal  capsule,  the  lower  half  provided  with  numerous  holes, 
the  upper  half  communicating  with  tube  B;  I,  II,  III,  marks  of  40,  56,  and  70  centimeters 
from  capsule;  C,  rubber  band  with  silk  thread  attached  to  end  of  tubing,  which  can  be  placed 
over  the  ear  of  the  patient;  F,  feeding  syringe;  E,  collapsible  connecting  tube;  D,  three-way 
stopcock. 


Einhorn's  Duodenal  Alimentation. — Einhorn^  has  devised  an 
instrument,  his  so-called  duodenal  pump,  by  which  food  can 
be  introduced  directly  into  the  duodenum  (Fig.  41). 

It  consists  of  a  small  metal  capsule  (14  mm.  long  and 
23   mm.    in    circumference),   perforated,   attached   to   but 

1  Presented  to  the  American  Gastroenterological  Association  at  its  Annual 
Meeting  held  at  St.  Louis,  Mo.,  June  6  and  7,  1910. 


438 


GASTRIC   ULCER 


detachable  from  a  long,  thin  rubber  tube  (8  mm.  in  circum- 
ference and  1  meter  long),  which  is  marked  at  40,  56,  70, 
and  80  centimeters  from  the  capsule,  and  at  the  other  end 
of  which  a  syringe  can  be  attached  (Fig.  41,  F). 

Einhorn,^  describing  the  use  of  his  duodenal  pump,  says 
that  feeding  is  begun  just  as  soon  as  there  is  no  longer 
any  doubt  that  the  end  of  the  tube  has  passed  beyond  the 


Fig.  42 


Duodenal  feeding.      (Einhorn.) 

pylorus.  The  food  should  be  introduced  very  slowly,  always 
at  body  temperature,  and  at  two-hour  intervals.  After 
each  feeding,  water  should  be  forced  through  the  tube,  and 
afterward  a  little  air,  to  expel  the  contents  of  the  pump  into 
the  duodenum,  after  which  the  stopcock  attachment  of 
the  tube  is  closed.  The  apparatus,  which  is  simple  in  con- 
struction, may  remain  in  the  digestive  tract  for  eight  to 
twelve  days  without  causing  undue  irritation  or  discomfort 
to  the  patient. 

Einhorn's  diet  in  duodenal  alimentation  consists  of  240  Co. 


1  Medical  Hcfonl,  January  If),  1010. 


EIXHORX'S  DUODENAL  ALIMENTATION  439 

(5viij)  of  milk,  one  raw  egg,  and  15  Gm.  (gss)  of  sugar  of 
niilk,  well  beaten.  This  amount  is  administered  at  a 
single  feeding.  When  it  is  desired  to  introduce  a  greater 
quantity  of  water  into  the  system  than  that  taken  during 
the  feeding  ]:)rocess,  a  quart  of  physiologic  salt  solution  may 
be  given  by  proctoclj^sis. 

The  patient  may  be  fed  while  in  the  sitting  posture,  as 
illustrated  in  Fig.  42. 

Since  the  duodenal  contents  may  be  aspirated  at  any 
time,  it  can  be  easily  ascertained  whether  or  not  the  pump 
has  entered  the  duodenum. 

Method  of  Procedure. — The  capsule  of  the  duodenal  pump 
and  the  lower  part  of  "the  rubber  tube  are  moistened  with 
warm  water  and  put  into  the  pharynx  of  the  patient.  Then 
the  patient  drinks  a  little  water,  and  the  instrument  soon 
passes  into  the  stomach.  To  be  certain  that  the  capsule 
does  not  stick  in  the  esophagus,  it  is  well  to  have  the  patient 
shake  his  abdomen,  when  a  syringeful  of  chyme  can  be 
aspirated  if  the  capsule  is  in  the  stomach.  Now  we  pass 
a  syringeful  of  water  and  then  one  of  air  through  the  instru- 
ment. The  rubber  tube  is  then  clamped  off  and  left  alone 
for  about  one  hour.  The  patient  is  told  not  to  close  his 
mouth  too  tightly,  so  that  the  tube  may  not  be  retarded 
in  its  wanderings.  He  must  also  avoid  intentional  swal- 
lowing. Through  the  peristalsis  of  the  stomach  the  capsule 
is  pushed  on  farther,  and  usually  passes  through  the  pylorus 
into  the  duodenum  and  later  into  the  upper  part  of  the  small 
intestine.  It  is  advisable  to  have  the  patient  read  some 
light  literature  in  order  to  divert  his  attention.  After  one 
hour  we  examine  how  far  the  capsule  has  progressed;  if 
the  mark  III  (indicating  70  centimeters  from  the  capsule) 
is  near  the  lips  or  inside  the  mouth,  we  try  to  aspirate. 
If  the  capsule  is  in  the  duodenum,  we  generally  obtain  a 
clear,  golden  yellow  or  watery  liquid,  of  alkaline  reaction 
and  somewhat  viscid  consistency.  If,  however,  it  is  in 
the  stomach,  we  obtain  an  acid  liquid  resembling  the  one 
first  removed.  This  can,  of  course,  occur  if  the  tube  Ues 
coiled  up  in  the  stomach.     Should  the  aspirated  material 


440  GASTRIC   ULCER 

be  acid,  we  must  partly  withdraw  the  tube,  after  putting 
water  and  air  through  it,  up  to  the  mark  II  (56  centimeters). 
The  tube  is  then  again  clamped  off,  and  after  one-half  to 
one  hour  the  procedure  is  repeated.  The  capsule  in  nearly 
all  cases  enters  the  duodenum  on  the  first  trial.  After 
having  fed  the  patient  for  ten  to  fourteen  days,  the  tube 
is  clamped  and  slowly  \\dthdrawn.  TMien  the  esophagus  is 
reached  the  patient  is  told  to  swallow,  and  during  this  act 
the  capsule  is  withdrawn.  Einhorn^  reports  several  cases 
which  have  been  successfully  fed  by  means  of  the  duodenal 
pump. 

William  Gerry  Morgan"  has  suggested  a  modification  of 
Einhorn's  method  of  duodenal  feeding  by  substituting  the 
iMurphy  drop  method.  He  attaches  to  the  upper  part  of 
the  duodenal  tube,  by  means  of  an  additional  section  of 
rubber  tubing,  a  porcelain-Uned  irrigator  of  500  Cc.  capacity. 
The  irrigator  is  placed  at  such  a  height  that  it  requires  about 
an  hour  for  300  Cc.  of  fluid  to  run  through  into  the  gut. 
He  begins  by  gi^dng  90  Cc.  of  the  milk,  egg,  and  lactose 
solution  every  two  hours,  and  gradually  increases  it  so  that 
by  the  end  of  the  first  day  the  patient  is  able  to  take  the 
300  Cc.  wdth  perfect  comfort.  His  patients  have  experienced 
no  inconvenience  from  the  continuous  presence  of  the 
duodenal  tube  in  situ,  and  the  feedings  have  frequently 
taken  place  while  they  were  sleeping  and  entirely  without 
their  knowledge.  In  addition  to  the  feeding,  ?^Iorgan  gives 
500  Cc.  of  normal  salt  solution  per  rectum,  by  the  drop 
method,  thus  adding  to  the  bod}"  fluids  and  keeping  the 
feces  soluble  and  the  bowel  actions  regular. 

Medicinal  Treatment. — By  the  administration  of  drugs  in 
the  treatment  of  gastric  ulcer,  an  endeavor  is  made  to 
stimulate  cicatrization,  to  cover  and  protect  the  ulcer  from 
chemical  irritation,  and  to  neutralize  the  gastric  acidity 
whether  due  to  the  normal  acid  or  to  any  of  the  abnormal 
acids  of  fermentation. 

Sir  Lauder  Brunton  maintains  that  in  a  large  percentage 

1  Medical  Record,  July  10,  1910.  ^  Lqc  cjt^ 


MEDICINAL  TREATMENT  441 

of  cases  of  gastric  ulcer  pain  can  be  stopped  by  the  admin- 
istration of  sodium  bicarbonate  in  large  dosage. '  The  best 
way  of  giving  the  medicine  is  to  dissolve  a  teaspoonful  in 
lime  water,  add  a  little  spirit  of  peppermint,  and  have  the 
patient  sip  the  solution  teaspoonful  by  teaspoonful  until 
the  pain  has  disappeared.  The  reason  for  using  lime  water 
is  that  the  bicarbonate  of  soda  in  plain  water  might  possibly 
soften  the  tissues  too  much,  and  thus  render  a  patient  who 
has  suffered  from  gastric  hemorrhage  more  liable  to  a 
recurrence.  To  lessen  the  constipating  effect  of  the  lime, 
fluid  magnesia  may  be  given  along  with  the  bicarbonate 
preparation.     An  alternative  formula  to  the  above  is: 

Gm.  or  Cc. 

I^ — Spiritus  menthae  piperitae 6.0  3iss 

Magnesii  oxidi 2.0  3ss 

Sodii  bicarbonatis 4.0  3j 

Cretse  prseparatse 2.0  5ss 

Misce. 

Sig. — A  teaspoonful  stirred  in  half  a  tumbler  of  water,  slowly  sipped,  a 
teaspoonful  at  a  time,  until  the  pain  is  relieved. 

Sodium  bicarbonate  holds  a  very  important  place  in  the 
treatment  of  gastric  ulcer.  The  quantity  required  to  over- 
come the  hyperacidity  and  diminish  the  pain  is  large, 
usually  10  to  15  Gm.  (5iiss-iv)  a  day.  Debove  recom- 
mends as  much  as  20  to  30  Gm.  (5v  to  §j)  a  day.  The 
dosage  must  vary  according  to  the  patient,  and  must  be 
increased  until  the  pain  ceases.  Lemoine  and  Debove  sug- 
gest the  addition  of  prepared  chalk  to  the  sodium  bicar- 
bonate— 0.5  Gm.  (7|  grains)  chalk  to  0.6  Gm.  (10  grains) 
sodium  bicarbonate  every  hour,  to  counteract  the  tendency 
to  diarrhea  likely  to  result  from  the  administration  of  large 
quantities  of  sodium  bicarbonate  alone.  Later  these  powders 
may  be  replaced  by  others  composed  of: 

Gm.  or  Cc. 
I^ — Sodii  bicarbonatis 0.60  gr.  x 

Cretse  prajparatae, 

Magnesii  oxidi aa       0.1.5  gr- ij 

Misce  et  ft.  pulv.  no.  i. 

Sig. — One  powder  every  hour  until  relieved. 


442  GASTRIC   ULCER 

The  proportions  of  chalk  and  magnesia  will  vary  in 
accordance  with  the  tendency  to  diarrhea  or  constipation 
on  the  part  of  the  patient.  Sodium  bicarbonate  by  itself 
has  the  objectionable  feature  of  easilj^  forming  sodium- 
lactate,  sodium  chloride,  and  other  purgative  salts.  This 
inconvenience  can  be  overcome  with  the  aid  of  chalk  or 
opium.  The  formation  of  sodium  chloride  is  a  grave  fault, 
as  this  salt  is  a  constant  source  of  hydrochloric  acid  in 
the  presence  of  gastric  juice.  To  overcome  this  objection, 
sodium  bicarbonate  should  always  be  combined  with  other 
alkahes  or  inert  powders  which  may,  in  part  at  least,  prevent 
the  formation  of  sodium  chloride.  The  following  combi- 
nations are  in  use;  each  is  for  one  powder,  which  may  be 
repeated  four  or  five  times  a  day : 

Gm.  or  Cc. 

Bf, — Sodii  bicarbonatis 1.0  gr.  xv 

Calcii  carbonatis 0.2  gr.  iij 

Bismuthi  subnitratis 0.3  gr.  v 

Misce. 

Gm.  or  Cc. 

I^ — Sodii  bicarbonatis 0.6  gr.  x 

Calcii  carbonatis     .      .  ...  0.2  gr.  iij 

Pulveris  talci 0.3  gr.  v 

Bismuthi  salic3^1atis 0.4  gr.  vj 

Misce. 

Gm.  or  Cc. 

I^ — Sodii  bicarbonatis 0 .  50  gr.  viij 

Cretse  prseparatse 0.25  gr.  iv 

Bi.smuthi  subnitratis 0 .  25  gr.  iv 

Pulveris  opii 0.01  gr.  ^'V 

Misce. 

Gm.  or  Cc. 

I^ — Sodii  bicarbonatis 0.60  gr.  x 

Magnesii  oxidi 0.20  gr.  iij 

Pulveris  talci 0.20  gr.  iij 

Pulveris  belladonnte  radicis     ...  0 .  02  gr.  y  j 

Misce. 

The  last  two  formulae  are  especially  intended  for  ulcer 
with  hypersecretion,  and  for  cases  with  pain.  To  favor 
cicatrization,  Lemoine  recommends: 

Gm.  or  Cc. 

I^ — Bismuthi  subnitratis lo.O  .~iv 

Tragacantha; 60.0  aij 

Misce. 

Sig. — To  be  taken  in  tablespoonful  doses  in  the  space  of  two  hours. 


MEDICINAL  TREATMENT  443 

This  is  to  be  continued  for  two  days  only,  when  the  doses 
of  bismuth  are  to  be  reduced  from  15  to  5  grannnes  for  the 
next  five  or  six  days,  at  the  end  of  which  time  the  bismuth 
should  be  stopped  and  the  ordinary  alkaline  treatment 
followed.  In  order  to  prevent  constipation  while  taking  the 
bismuth,  0.25  to  4  Gm.  (4  to  60  grains)  of  magnesia  may 
be  taken  daily,  at  the  same  time  that  the  bismuth  is  admin- 
istered.^ 

Einhorn,  in  most  cases  of  gastric  ulcer,  whether  compli- 
cated with  hemorrhages  or  not,  gives  large  doses  of  bismuth. 
Two  grammes  (30  grains)  of  bismuth  subnitrate  are  given 
either  alone  or  with  0.2  to  0.8  Gm.  (3  to  12  grains)  of  mag- 
nesium oxide,  varying  the  dose  of  the  latter  until  one  stool 
a  day  results.  This  powder  is  given  three  times  a  day,  half 
an  hour  before  meals,  in  a  wineglass  of  water. 

In  the  treatment  of  gastric  hemorrhage  Einhorn  gives 
adrenalin  (1  to  1000)  in  5-  to  15-drop  doses  by  mouth.  He 
also  administers,  per  rectum,  calcium  lactate,  1  to  2  Gm. 
(15  to  30  grains)  twice  daily  in  150  Cc.  (§v)  of  water.  Small 
doses  of  codeine  and  atropine  are  administered  occasionally 
when  pains  are  severe. 

Bismuth  preparations  were  employed  over  a  century  ago 
by  Odier  as  a  panacea  for  spasm  of  the  stomach.  The  use 
of  bismuth  in  the  treatment  of  gastric  ulcer  was  suggested 
about  the  middle  of  last  century  by  Budd  and  Trousseau. 
It  remained,  however,  for  Fleiner,  following  the  advice  of 
Kussmaul,"  to  bring  the  bismuth  treatment  impressively  to 
the  notice  of  the  profession.  The  method  which  is  strongly 
advocated  by  Fleiner  is  as  follows:  The  fasting  stomach 
is  washed  out  each  morning  until  the  returning  water  is 
clear  and  the  reaction  neutral.  Then  a  suspension  of  bis- 
muth subnitrate  in  water  (10  to  20  Gm.  in  200  Cc.)  is 
introduced  into  the  stomach  by  means  of  the  tube.  The 
tube  is  withdrawn  and  the  patient  is  requested  to  lie  in 
such  a  posture  that  the  bismuth  may  lodge  by  gravitation 
over  the  supposed  site  of  the  ulcer.    Breakfast  is  taken  after 

1  La  Quinzaine  therapeutique,  September  25,  1907. 

^  Verhandlungen  des  12  Kongresses  fiir  innere  Medicin,  1893. 


444  GASTRIC   ULCER 

half  an  hour's  rest.  The  bismuth  treatment  should  be  em- 
ployed daily  at  the  beginning;  later,  every  other  day  or 
every  third  day.  It  should  be  continued  as  long  as  necessary. 
Boas  prefers  the  subcarbonate  of  bismuth  to  the  subnitrate. 
The  favorable  results  of  Fleiner  have  been  corroborated  by 
Fischer,  Cramer,  Saveheff,  and  Witthauer. 

Such  treatment  should  result  in  a  diminution  of  the  gastric 
distress  and  a  cessation  of  pain,  nausea,  and  vomiting. 
The  use  of  bismuth  is  begun  at  the  same  time  as  the  gastric 
feeding  at  the  close  of  the  initial  starvation  period.  Fleiner 
claims  for  the  bismuth  an  antiseptic  and  astringent  action, 
as  well  as  a  direct  action  to  reduce  the  hj^Deracidity.  In 
large  doses  it  has  a  mechanical  protective  effect.  The  use 
of  the  stomach  tube  is  not  a  necessity  for  the  introduction 
of  the  bismuth  into  the  stomach;  the  suspension  may  be 
swallowed. 

Pariser  advocates  the  administration  of  15  to  20  Gm. 
(oiv-v)  of  bismuth  subnitrate  in  water  on  an  empty 
stomach  in  the  morning,  to  be  followed  by  a  httle  pure 
water.  The  patient  is  directed  to  lie  quietly  on  his  back 
for  three-ciuarters  of  an  hour,  after  which  he  is  permitted 
to  take  a  cup  of  coffee  and  a  roll.  Pariser  says  he  has  never 
seen  any  toxic  effects  from  such  large  doses  of  bismuth. 
He  has,  however,  substituted,  as  a  matter  of  economy,  a 
mixture  of  60  Gm.  (§ij)  each  of  chalk  and  talcum,  to  which 
is  added  15  Gm.  (§ss)  of  magnesium  oxide.  There  is  an  addi- 
tional advantage,  too,  in  the  laxative  and  antacid  effects 
of  these  drugs,  as  well  as  in  the  fact  that  they  do  not  darken 
the  stools  and  thus  conceal  slight  hemorrhages  which  in  the 
bismuth  treatment  might  pass  unobserved. 

Riegel  has  stated  that  he  never  limited  himself  to  the 
administration  of  bismuth,  but  always  insisted  on  rest  and 
a  careful  regulation  of  the  diet  at  the  same  time.  He  never 
ordered  bismuth  suspension  to  be  introduced  into  the 
stomach  by  tube,  but  simply  directed  the  patients  to  drink 
the  suspension — as  a  rule,  in  one  dose  of  10  Gm.  (oiiss)  some 
time  in  the  course  of  the  forenoon  when  the  stomach  was 
empty.    "I  can  corroborate,"  says  Riegel,  "the  statement 


MEDICINAL   TREATMENT  445 

that  the  effect  of  this  remedy  is  very  favorable.  I  feel  jus- 
tified, therefore,  in  recommending  bismuth  as  a  valuable 
adjunct  to  the  dietetic  rest  cure.  I  advise  its  administra- 
tion in  all  cases  of  ulcer  of  the  stomach." 

Bismuth  subnitrate  is  a  salt  formed  by  the  combination 
of  bismuth  with  nitric  acid.  Nitric  acid  is  caustic,  anti- 
septic, and  astringent.  Bismuth  subnitrate  is  insoluble  in 
water,  and  passes  quite  well  through  the  stomach  into  the 
duodenum  without  much  change.  It  has  been  proved  by 
the  .T-rays  that  in  the  presence  of  ulcer  some  of  the  bismuth 
adheres  to  its  raw  surfaces.  While  adhering,  the  subnitrate 
disintegrates  slightly  and  liberates  some  of  its  nascent  nitric 
acid,  which  acts  locally  as  a  stimulant,  astringent,  and  anti- 
septic. The  nascent  nitric  acid  coagulates  the  albuminous 
surface  of  the  ulcer,  which  thus  acts  as  a  protective  during 
the  time  of  healing.  If  the  practitioner  has  this  object  in 
view,  he  should  not  prescribe  bismuth  subnitrate  with  an 
alkali,  for  the  alkali  w^ould  destroy  the  small  quantity  of 
nascent  acid  developed.  It  is  impossible  to  secure  as  good 
a  result  in  the  treatment  of  gastric  ulcer  with  any  other 
salt  of  bismuth  as  with  the  subnitrate.  The  inefficiency  of 
bismuth  subcarbonate  is  due  to  the  absence  of  nitric  acid; 
in  the  decomposition  of  the  subcarbonate,  carbon  dioxide 
is  evolved.  I  have  used  large  doses  of  subnitrate  of  bismuth 
in  the  treatment  of  gastric  and  duodenal  ulcer  for  the  past 
eighteen  years,  without  one  case  showing  symptoms  of  ill 
effect.  I  prescribe  it  in  aqueous  suspension  only,  to  be  taken 
before  meals,  three  times  a  day.  The  bismuth  should  be 
continued  for  one  to  four  weeks  during  the  cure.  I  give  it 
as  in  the  following  prescription: 


Gm.  or  Cc. 

I^ — Bismuthi  subnitratis,  c.  p. 

.      .      .      60.0             5ij 

Aquae  destillatse     .... 

q.  3.  ad    240.0             Sviij 

Misce. 

Sig. — Shake  well.     Tablespoonful 

three  times  a  day,  before  meals, 

S.  Fenwick  and  W.  S.  Fenwick^  always  use  the  oxide  of 
silver  in  the  form  of  a  pill  in  the  treatment  of  gastric  ulcer, 

1  Ulcer  of  the  Stomach  and  Duodenum,  1900. 


446  GASTRIC   ULCER 

commencing  with  half  a  grain  and   cautiously  increasing 
to  one  grain,  with  the  necessary  intermissions.     The  silver 
salts  are  particularly  valuable  when  hypersecretion  accom- 
panies organic  disease.    As  to  bismuth,  Fenwick  prefers  the 
subcarbonate  to  the  subnitrate,  since  it  has  the  merit  of 
neutralizing  to  some  extent  the  excessive  acidity  of   the 
gastric  contents.     His  usual  custom  is  to  prescribe  0.6  to 
1  Gm.  (9  to  15  grains)  of  the  subnitrate  or  subcarbonate  of 
bismuth  with  an  equal  quantity  of  bicarbonate  of  sodium 
and  a  few  drops  of  a  solution  of  morphine,  shortly  before 
meals,  and  in  the  majority  of  cases  this  one  dose  is  sufficient 
to   afford   relief.     Occasionally,    however,    a   much   larger 
amount  of  the  bismuth  is  required,  and  Fleiner  has  shown 
that  8  to  12  Gm.  (5ij-iij)  may  be  given  at  a  time  with- 
out any  danger  of  toxic  symptoms.     Owing  to  the  dangers 
which  accompany  the  use  of  the  stomach  tube  in  cases  of 
gastric   ulcer,   Fenwick  prefers   to   administer  these   large 
doses  of  bismuth  by  mouth,  and  suggests  the  following  plan: 
About  one  hour  before  breakfast  the  patient  assumes  the 
posture  requisite  to  bring  the  powder  in  contact  with  the 
ulcer,   and  then  quickly  swallows  about  eight  ounces  of 
warm  water  in  which  8  to   12  Gm.  (oij-iij)  of  subcarbo- 
nate of  bismuth  has  been  suspended.     He  remains  quiet  for 
one  hour,  and  then  partakes  of  breakfast.    This  modification 
of  Fleiner's  method  has  been  employed  frequently  with 
marked  success.     For  the  first  fortnight  the  dose  is  given 
each  morning,  during  the  next  fortnight  on  alternate  days, 
and  subsequently  once  or  twice  a  week. 

Nitrate  of  silver  has  been  used  for  a  long  time  in  the 
treatment  of  gastric  ulcer.  Johnson,  who  was  the  first  to 
recommend  it,  had  observed  that  in  his  cases  of  epilepsy 
all  the  gastric  symptoms  disappeared  after  the  administra- 
tion of  nitrate  of  silver.  Gerhardt  claims  to  have  seen  many 
cases  in  which  all  gastric  symptoms  caused  by  ulcer  cleared 
up  after  a  course  of  nitrate  of  silver;  he  says  the  siher  salt 
acts  favorably  in  cases  in  which  pain  is  ]iresent  when  the 
stomach  is  empty.  It  probably  has  the  effect  of  an  antacid 
in  such  cases.     Cohnheim  recommends  nitrate  of  silver  in 


MEDICINAL  TREATMENT  447 

cases  of  acute  chlorotic  ulcer,  reserving  bismuth  for  other 
forms  of  gastric  ulcer.  Boas  recommends  the  silver  nitrate 
treatment,  particularly  in  mild  cases  of  ulcer  and  in  fol- 
licular ulcers.  The  treatment  should  be  begun  by  giving, 
always  on  an  empty  stomach,  a  solution  of  0.2  Gm.  (3 
grains)  in  120  Cc.  (oiv)  of  distilled  water,  in  tablespoonful 
doses,  three  times  a  day.  Boas  increases  the  strength  of 
the  solution  to  0.3  Gm.  (5  grains),  and  later  to  0.4  Gm. 
(7  grains),  to  each  four  ounces  of  water.  The  physician 
should  insist  upon  a  careful  regulation  of  the  diet. 

Gm.  or  Cc. 

I^ — Argenti  nitratis 0.3  gr.  v 

Aquae  destillatse 180.0  5vj 

Misce. 

Sig. — A  tablespoonful  in  a  wineglass  of  water  three  times  a  day,  half  an 
hour  before  meals. 

Care  should  be  exercised  in  the  administration  of  silver 
salts,  lest  the  condition  known  as  argyrism  result  from  their 
too  long  continued  use. 

W.  H.  Thomson,  of  New  York/  is  strongly  in  favor  of 
resorcinol  as  a  remedy  in  local  inflammatory  conditions 
of  the  stomach  and  in  gastric  ulcer.  He  prescribes  it  very 
frequently  in  cases  where  there  is  throbbing,  with  rigidity 
and  tenderness  on  palpation,  at  the  epigastrium.  When  the 
signs  of  gastric  ulcer  are  unmistakable,  such  as  hematem- 
esis,  or  palpable  thickening  about  the  pylorus,  resorcinol 
is  advised  as  soon  as  the  hemorrhage  is  checked.  Thomson 
has  also  used  this  drug  in  gastric  disorders  sequent  to  gall- 
stone disease.  Prof essor  Fraser,  of  Edinburgh,  recommends 
bichromate  of  potash  for  such  conditions.  Both  these 
agents  are  powerful  antacids,  arresting  local  fermentation. 
Resorcinol  may  be  administered  internally  as  follows 
(Thomson) : 

Gm.  or  Cc. 

I^ — Resorcinolis 12.0  3iij 

Tincturse  nucis  vomica; 15.0  3iv 

Syrupus  zingiberis 8.0  3ij 

Aquse  menthse  piperita;      .      .      .       q.  s.  ad    240.0  Oss 

Misce. 

Sig. — Two  teaspoonfuls  in  water,  half  an  hour  after  meals. 
iNew  York  Medical  Journal,  June  11,  1910. 


448  GASTRIC   ULCER 

Gm.  or  Cc. 

I^ — Potassii  bichromatis .0.1  gr.  iss 

Bismuthi  subcarbonatis 6.0         5iss 

Extracti  gentianae,  q.  s. 

^lisce  et  div.  in  pil.  no.  xxx. 

Sig. — Take  one,  half  an  hour  before  meals.     (Fraser.) 

Olive  oil,  owing  to  its  high  nutritive  value  and  its  abso- 
lutely unirritating  properties,  is  a  therapeutic  agent  worth 
a  careful  trial.  It  has  a  decided^  restraining  action  upon 
the  hydrochloric  acid  secretion  of  the  gastric  juice.  In 
recent  cases  several  spoonfuls  of  the  oil  maj^  be  administered 
daily,  the  patient  rinsing  the  mouth  with  some  good  mouth 
wash  each  time  after  taking  the  dose.  The  quantity  of 
oil  is  gradually  increased  up  to  150  Cc.  (ov)  per  day,  taken 
in  three  portions.  If  the  patient  evinces  a  disgust  for  the 
pure  oil,  it  may  be  given  as  an  emulsion  through  a  soft 
esophageal  tube.  All  other  feeding  by  the  mouth  is  sus- 
pended so  long  as  grave  symptoms  exist — that  is  to  say, 
for  three  to  six  days.  There  is  nothing  to  prevent  giving 
nutritive  enemata,  since  the  oil,  as  a  rule,  does  not  produce 
diarrhea,  though  it  usually  relieves  the  constipation  from 
which  patients  with  ulcer  of  the  stomach  are  apt  to  suffer. 
Generally  in  eight  days  the  digestive  trouble  disappears, 
but  it  is  wise  to  continue  the  oil,  associated  with  an  appro- 
priate diet,  for  two  weeks  longer.  This  treatment  is  particu- 
larly efficacious  in  chronic  ulcer  of  the  stomach,  even  when 
surgical  operation  proves  of  no  avail. 

Bloch  relates  his  experience  with  nineteen  cases  of  gastric 
ulcer  or  pyloric  stenosis  in  which  great  benefit  was  derived 
from  small  amounts  of  oil  taken  three  times  a  day.  It  was 
remarkable,  he  states,  how  rapidly  the  pain  was  relieved 
and  the  debilitated  patients  recovered  strength.  This  was 
most  evident  in  the  cases  of  enlargement  of  the  stomach 
from  spasm  of  the  pylorus.  Almost  complete  recovery  was 
realized  in  a  few  cases  of  severe  stenosis,  the  treatment 
restoring  the  working  capacity  of  the  patients.  In  private 
practice  this  writer  prefers  oil  of  sweet  almonds,  changing 
after  two  weeks,  if  the  patient  desires,  to  "almond  milk," 


MEDICINAL   TREATMENT  449 

which  is  an  emulsion  of  a  tablespoonful  of  pulverized  sweet 
almonds  in  a  glass  of  hot  water,  to  be  swallowed  warm, 
with  peppermint  drops  afterward  if  desired.  In  winter  he 
prefers  an  emulsion  made  according  to  the  following  formula 
(with  or  without  the  belladonna) : 

Gm.  or  Cc. 
I^ — Tinctunv  bclladonnse 5.0  5j 

Olei  amygdala^  express! 30.0  5j 

Vitelli  ovi  unum 

Aquae  destillata? ad    200.0  5vj 

Misce  et  ft.  emulsio. 

Sig. — A  tablespoonful  three  times  a  day. 

The  proportion  of  oil  can  be  increased  or  reduced  accord- 
ing to  the  severity  of  the  case.  In  some  cases  Bloch  gives 
pure  olive  oil  or  cottonseed  oil. 

I  have  used  tincture  of  iodine,  a  five-drop  dose  in  a  wine- 
glass of  water  to  be  taken  three  times  a  day  on  an  empt}^ 
stomach.  This  treatment  has  allayed  the  pain  and  put  the 
patient  at  ease  when  other  therapeutic  agents  were  inef- 
fectual. 

In  the  treatment  of  hemorrhage  from  the  stomach  (see 
chapter  on  Gastric  Hemorrhage)  during  and  following  a 
serious  crisis  in  the  patient's  illness,  Pron^  advises  the  appli- 
cation of  an  ice  bag  to  the  pit  of  the  stomach,  supporting  it 
on  a  hoop  or  some  similar  arrangement  so  as  to  prevent  the 
weight  of  the  bag  from  annoying  the  patient.  The  taking 
of  any  fluid  by  the  mouth  is  to  be  absolutely  forbidden. 
It  is  only  permitted  to  rinse  out  the  mouth  occasionally 
mth  either  plain  or  aromatized  water;  and  the  patient  may, 
if  he  wishes,  suck  small  pieces  of  ice.  To  furnish  the  tissues 
Tvdth  the  fluid  needed  by  them,  an  enema  of  boiled  water 
(one  pint)  is  given  twice  a  day. 

As  to  diet  during  convalescence,  iced  milk  should  con- 
stitute the  only  food  for  several  days,  two  to  three  ounces 
being  given  during  the  day.  One-third  of  a  cup  of  water 
may  be  allowed  daih%  and  the  quantity  gradually  increased 
to  a  pint.     In  a  few  days,  as  the  patient  improves,  the 

1  La  Quinzaine  therapeutique,  September  10,  1909. 
29 


450  GASTRIC   ULCER 

amount  of  water  taken  may  be  increased  to  two  or  three 
quarts  a  day. 

If  the  hemorrhage  persists,  the  patient  must  be  put  on  a 
more  rigid  diet,  the  quantity  of  milk  being  decreased,  and 
nutriment  administered  by  rectum.  The  following  nutritive 
enemata  are  proposed: 

(1) 

Gm.  or  Cc. 

I^ — Eggs,  two 

Milk 240.0  Bviij 

Tincture  of  opium 0.3  gtt.  v 

Miisce. 

(2) 

Gm.  or  Cc. 

IJ — Eggs,  two 

Milk 240.0  5viij 

Liquid  peptone 8.0  oij 

Misce. 

(3)  Robin  uses  the  following  enema : 

Gm.  or  Cc. 

I^ — Eggs,  one  to  three 

Liquid  peptone       .      .      .      .  .     38 . 0  to  48 . 0  5  ^'-^^i J 

Solution  of  glucose  (20  per  cent.)       .  100.0  oiij 

Sea  salt 1.5  gr.  xxij 

Pepsin 0.5  gr.  viiss 

Tincture  of  opium 0.2  gtt.  iij 

Freshly  prepared  soup           to  make  240.0  o^iij 

Misce. 

At  the  first  appearance  of  hemorrhage,  give  a  hypodermic 
injection  of  ergotin,  and  repeat  as  needed  two  or  three  times 
during  the  twenty-four  hours;  or  give  the  following: 

Gm.  or  Cc. 

I^ — Hydrastinse  hydrocbloridi  0.5  gr.  viiss 

Aquae  destillata;    .      .  .  .10.0  5iiss 

Misce. 


ANTI LYTIC  SERUM  TREATMENT  451 

Or  this  formula  of  Capitan: 


Gm.  or  Cc 

F^ — Extracti  ergotae 5.0 

gr.  l.x.w 

Morphinae  hydrochloridi 0.035 

gr.  }! 

Antipyrina!        ....            .      .      -            1.5 

gr.  xxij 

SparteiniE  sulphatis 0.2 

gr.  iij 

Atropinaj  sulphatis             0 .  02 

gr.  -k 

Aquae  destillatae      ....      q.  s.  ad          10. 0 

5iiss 

Misce. 

Sig. — A  Pravaz  syringeful  to  be  injected  every  half-hour 

or  quarter-hour 

as  needed,  but  no  more  than  five  syringefuls  in  all  to  be  used. 

Gm.  or  Cc. 

4.0 

3j 

8.0 

3ij 

2.0 

gr.  XXX 

0.5 

gr.  vuss 

0.6 

TTLx 

150.0 

5v 

All  other  measures  failing,  prescribe  the  following  mixture 
to  be  taken  in  tablespoonful  doses  every  hour: 


I^ — Calcii  chloridi 

Tincturse  opii 

Extracti  ergotae 

Acidi  gallici 

Spiritus  terebinthinse 

Aquae  menthae  piperitse      .      .       q.  s.  ad 
Misce. 
Sig. — One  tablespoonful  every  hour. 

Treatment  by  Antilytic  Serum. — Antilytic  serum  has  recently 
been  employed  with  some  success  in  the  treatment  of  gastric 
ulcer.  The  serum  of  a  healthy  individual  contains,  in  addi- 
tion to  its  other  constituents,  a  substance  which  stimulates 
the  repair  of  tissue  cells  and  limits  cell  destruction  by 
antagonizing  certain  enzymes  of  fixed  and  wandering  cells. 
These  bodies  are  of  the  nature  of  antitrypsin  and  are  attached 
to  the  albuminous  portion  of  the  serum;  they  have  been 
called  antilysins.^  Antilytic  serum  recommended  for  use 
is  the  normal  blood  serum  of  the  horse,  fresh,  atoxic,  and 
sterile,  in  the  natural  condition  or  with  its  antilytic  valency 
increased  by  the  addition  of  globulin-free  serum.  The  treat- 
ment is  applicable  to  cases  of  gastric  ulcer  with  or  without 
hemorrhage.  No  other  drug  should  be  administered, 
except  a  simple  purgative  as  required.  The  physician  must 
insist  upon  complete  rest  in  bed  for  two  to  three  weeks. 

1  Hort,  British  Medical  Journal,  August  10,  1908,  p.  1081. 


452  GASTRIC   ULCER 

The  antilytic  serum  is  administered  by  mouth  three  to 
four  times  a  day,  immediately  after  meals,  each  dose  in 
half  an  ounce  of  water.  If  pain  is  severe,  60  to  80  Cc. 
(§ij-iiss)  is  given  in  divided  doses  in  the  twenty-four  hours. 
In  all  severe  cases  the  serum  treatment  should  be  con- 
tinued for  six  weeks.  Marked  relief  from  pain  has  been 
experienced  within  twenty-four  hours  after  the  beginning 
of  the  treatment.    Hort  and  others  report  favorable  results. 

The  diet  during  the  antilytic  serum  treatment  should  be 
given  in  small  quantities  and  should  consist  of  stale  bread, 
yolks  of  lightly  cooked  eggs,  and  white  meat  of  chicken. 
No  milk,  soup,  or  fish  should  be  permitted  at  any  time. 
The  only  liquid  permissible  is  ten  ounces  of  water  at  7  a.m., 
11  A.M.,  and  10  P.M.  If  the  patient  shows  signs  of  improve- 
ment the  diet  may  be  doubled  in  quantity  at  the  end  of 
four  to  five  days.  On  the  seventh  day  finely  chopped  meat 
hghtly  cooked  may  be  added.  By  the  end  of  the  second 
week  meat  in  the  form  of  beef  and  mutton  may  constitute 
the  chief  article  of  diet.  In  three  weeks  from  the  beginning 
of  the  treatment  full  diet  may  be  prescribed.  The  patient 
should  not  partake  of  alcohol,  soup,  tea,  coffee,  or  starch 
foods  for  at  least  six  months. 

Treatment  by  Bacterial  Vaccines. — The  treatment  of  gastric 
ulcer  by  means  of  bacterial  vaccines  was  suggested  to  the 
author  by  the  work  of  Turck  on  the  experimental  produc- 
tion of  gastric  ulcer.  Turck  succeeded  in  a  few  instances 
in  producing  peptic  ulcer  in  guinea-pigs  by  long-continued 
close  confinement  without  exercise  and  with  limited  light 
and  ventilation.  These  few  successes  suggested  the  possi- 
bihty  of  systemic  conditions  being  important  factors,  and 
that  alterations  in  the  toxic  state  of  the  alimentary  canal 
with  consequent  change  in  the  blood  might  play  some  part. 
Experiments  were  begun  with  the  Bacillus  coli  connnunis 
because  that  organism  is  found  abundantly  in  the  intestine 
and  flourishes  in  catarrhal  and  atonic  states  of  the  stomach. 
Although  no  difference  could  be  detected,  in()ri)hologically 
or  culturally,  ))etwoon  strains  isolated  from  the  stools  of 
normal  individuals  and  those  from  cases  of  gastric  ulcer, 


'       BACTERIAL   VACCINE  TREATMENT  453 

the  latter  were  selected  on  account  of  the  possibility  of 
there  being  a  difference  in  the  toxicity  of  the  two  strains. 
The  toxin  of  the  Bacillus  coli  communis  being  intracellular 
suggested  the  use  of  killed  as  well  as  living  cultures.  In 
the  earlier  experiments  the  bacteria  were  introduced  directly 
into  the  circulation,  but  later  they  were  fed  by  mouth, 
thus  approaching  more  nearly  the  natural  conditions.  Meat 
extractives  were  fed  with  the  bacteria  in  some  cases,  as  it 
was  observed  that  the  bacillus  grew  most  abundantly  in 
media  containing  meat  extractives.  Positive  results  were 
obtained  in  every  experiment  in  which  the  cultures  were  fed 
to  dogs,  the  number  and  extent  of  the  ulcers  varying  from 
a  few  in  the  duodenum  to  numerous  typical  peptic  ulcers 
of  the  stomach.  In  order  to  ascertain  the  percentage  of 
gastric  ulcer  in  dogs  not  experimented  with,  the  stomachs 
and  intestines  of  189  healthy  dogs  killed  at  the  dog  pound 
and  of  82  dogs  dying  from  disease,  injury,  or  poisoning, 
w^ere  systematically  examined.  In  no  case  was  a  peptic 
ulcer  found;  it  appears,  therefore,  that  the  percentage  of 
its  natural  occurrence  must  be  very  small.  Turck  thinks 
a  dual  condition  is  indicated  in  the  production  and  persist- 
ence of  the  ulcers — a  toxic  condition  overcoming  natural 
resistance,  and  possibly  some  chemical  substance  formed 
within  the  alimentary  tract  which,  when  absorbed,  may 
neutralize  the  protective  bodies  in  the  blood  and  tissues, 
resulting  in  autocytolysis.  We  have  in  these  results,  the 
author  holds,  a  positive  etiological  factor  of  gastric  ulcer, 
and  have  now  a  firm  basis  for  the  unravelling  of  the  funda- 
mental or  underlying  etiology  of  peptic  ulcer. 

This  work  of  Turck  is  valuable  from  a  therapeutic  view- 
point when  we  consider  the  opsonic  work  of  Sir  A.  E. 
Wright  and  his  vaccines  made  of  dead  bacterial  suspensions.^ 
According  to  the  revised  views  which  Wright  now  holds, 
and  which  were  developed  through  his  use  of  various 
bacterial  substances  in  the  form  of  vaccines,  opsonin  is 
an  ingredient  of  the  blood  serum  w^hich  aids  phagocytosis 

1  Aaron,  Observations  of  Opsonic  Therapy,  New  York  ]\Iedical  Journal, 
December  1,  1906. 


454  GASTRIC   ULCER 

by  its  inhibiting  action  on  a  given  microorganism.  That  is 
to  say,  it  acts  on  the  microbe  and  prepares  it  to  be  ingested 
by  the  protective  body  cells  or  phagocytes,  chief  among 
which  are  the  polynuclear  leucocytes  of  the  circulating 
blood.  The  blood  serum  of  man  contains  opsonins  for 
various  pathogenic  bacteria,  and  in  a  state  of  health  this 
opsonic  content,  or  ''opsonic  index,"  as  it  is  called,  is  at  a 
certain  or  normal  level.  By  an  ingenious  method,  devised 
bj"  Wright  and  Douglas,  the  opsonic  index  for  an}^  particular 
pathogenic  microbe  can  be  determined.  This  method  con- 
sists essentialh^  in  mixing  with  fresh  human  leucocytes  the 
serum  to  be  tested  and  an  emulsion  of  the  particular  bac- 
terium under  investigation.  After  a  brief  incubation  this 
mixture  is  spread  as  in  making  a  blood  film,  stained  appro- 
priately, and  then  examined  vAih.  suitable  microscopic 
power.  The  phagocytic  leucocytes  will  now  be  revealed 
containing  the  bacteria  in  their  substance;  and  by  counting 
the  contained  bacteria  in  a  sufficient  number  of  leucocytes, 
striking  an  average,  and  comparing  it  with  a  normal  serum, 
the  opsonic  index  for  that  particular  serum  and  that  partic- 
ular microbe  is  obtained. 

The  chief  merit  of  Wright's  work  consists  in  his  success, 
by  the  use  of  bacterial  vaccines,  in  artificially  stimulating 
the  flagging  opsonic  power  of  the  blood  of  the  patient. 
From  this  it  would  seem  rational  to  use  the  colon  vaccine 
in  the  treatment  of  gastric  ulcer.  I  have  so  used  it,  admin- 
istering a  bacterial  suspension  of  40,000,000,  hypodermically, 
once  a  week.  There  were  apparently  no  untoward  results, 
though  it  is  rather  early  to  accord  the  treatment  a  perma- 
nent place  in  the  therapeutics  of  ulcer  of  the  stomach. 

Surgical  Intervention. — The  indications  for  surgical  interven- 
tion are  given  by  Einhorn  as  follows:  (1)  In  large  recurrent 
gastric  hemorrhages  threatening  life  the  ulcer  should  be 
excised  in  the  interval,  or  a  gastroenterostomy  established 
to  prevent  renewed  hemorrhage.  (2)  Small  losses  of  blood 
that  cannot  be  checked  and  that  endanger  life  through 
their  persistence  should  be  dealt  with  surgically.  (3)  Per- 
foration of  the  ulcer  demands  always  immediate  operation 


SURGICAL  INTERVENTION  455 

(excision  or  invagination  of  the  defect,  and  suture)  as  soon 
as  the  diagnosis  has  been  made.  (4)  An  ulcer  situated  at 
the  pylorus  and  attended  with  peristaltic  restlessness  of 
the  stomach  and  continuous  hypersecretion  indicates  opera- 
tion. (5)  Advanced  cases  of  stenosis  of  the  pylorus  require 
gastroenterostomy.  (6)  Gastric  ulcers  with  formation  of 
tumor,  no  matter  where  the  location  may  be,  always  demand 
gastroenterostomy,  usually  with  excision  of  the  tumor. 

Clairmont  believes  that  the  value  of  gastroenterostomy 
in  gastric  ulcer  is  dependent  upon  the  situation  of  the  ulcer; 
the  nearer  it  is  to  the  duodenum  the  better  the  prognosis. 
He  figures  that  an  ulcer  at  or  near  the  pylorus  will  be  favor- 
ably influenced  by  gastroenterostomy  in  about  62  per  cent, 
of  the  cases,  at  a  distance  from  the  pjdorus  in  47  per  cent., 
and  in  the  duodenum  in  73  per  cent. 

Musser  is  inclined  to  be  very  conservative  in  the  matter 
of  operative  procedure  for  gastric  ulcer.  The  more  he  sees 
of  the  results  of  surgery,  the  more  he  feels  that  we  must 
go  very  slowly  mth  regard  to  advising  abdominal  section, 
particularly  when  we  do  not  have  the  opportunity  of  select- 
ing the  surgeon.  Operation,  which  under  certain  circum- 
stances is  extremely  grave,  should  be  considered  carefully 
and  in  all  its  aspects  before  being  decided  upon.  Medical 
measures  can  bring  about  relief  and  perhaps  cure  in  a 
large  proportion  of  cases,  particularly  acute  ones. 

"\V.  J.  Mayo^  states  that  acute  ulcers  should  be  treated 
medically,  surgery  having  only  to  do  with  the  complica- 
tions, such  as  perforation,  hemorrhage,  and  obstruction. 
Chronic  ulcers  should  be  considered  medically  so  long  as  the 
patient  maintains  good  nutrition  and  is  not  unfitted,  more 
or  less,  for  life's  work  by  reason  of  pain  and  digestive  dis- 
turbances. Chronic  ulcer  becomes  surgical  when  repeated 
medical  "cures"  have  demonstrated  the  futility  of  further 
continuance  of  such  treatment,  and  especially  if  there  are 
mechanical  difficulties  present,  such  as  obstruction,  stagna- 
tion or  retention  of  food,  or  adhesions.  The  possibifity  of 
ulcer  degenerating  into  cancer  would  not  of  itself  justify 

1  Mobile  Medical  and  Surgical  Journal,  June,  1906. 


456  GASTRIC  ULCER 

operation,  but  it  must  be  taken  into  consideration  in  sum- 
ming up  the  indications  for  surgical  intervention. 

A  simple  uncomplicated  gastric  ulcer  is  not,  in  my  opinion, 
a  case  for  surgical  intervention.  Only  in  the  event  of  com- 
phcations,  or  in  ulcers  which  defy  thorough  internal  treat- 
ment, impairing  nutrition  by  interference  with  motility, 
is  there  any  indication  for  surgical  treatment.  The  fact 
should  always  be  taken  into  consideration  that  in  the  present 
state  of  the  art  of  diagnosis  we  can  have  only  a  suspicion 
as  to  the  seat  of  the  ulcer.  We  know  that  four-fifths  of  all 
gastric  ulcers  are  situated  at  the  lesser  curvature  on  the 
posterior  wall  of  the  stomach — a  surgically  inaccessible 
place.  Unless,  therefore,  there  is  a  well-developed  ulcer 
of  the  pylorus,  which  has  been  diagnosticated  by  the  signs 
of  retention,  it  is  impossible  to  make  a  safe  prognosis  of 
recovery  or  even  of  improvement  through  surgical  means. 
In  some  cases,  after  ulcer  of  the  stomach  had  been  diag- 
nosticated and  the  abdominal  cavity  opened,  either  the 
ulcer  has  not  been  found,  or,  if  found,  adhesions  or  an 
unfavorable  position  of  the  lesion  have  rendered  operation 
impracticable. 

So  far  as  surgery  is  available,  no  procedure  but  removal 
of  the  ulcer  by  excision  or  gastroenterostomy  is  to  be 
considered.  However,  excision  of  the  ulcer  does  not  remove 
the  cause  nor  the  tendency  to  re-formation;  nor  does  it 
improve  motility.  Neither  does  it  reduce  hyperacidity; 
but  it  does  remove  the  dangers  accompanying  the  ulcer, 
such  as  hemorrhage,  perforation,  and  malignant  degenera- 
tion. Gastroenterostomy  and  favorable  drainage  protect 
the  ulcer  from  irritation  by  the  hyperacid  gastric  contents, 
and  some  ulcers  which  have  defied  every  kind  of  therapy 
will  sometimes  heal  or  become  latent  after  this  operation. 
Ulcers  of  the  pj^lorus  or  duodenum  can  be  cured  by  gastro- 
enterostomy, but  no  others. 

After   an   exhaustive   study ^  of   the   results  of   internal 

'  Die  innere  und  die  chirurgische  Behandlung  des  chrouischen  Magenge- 
sch\vurs  und  ihrc  Erfolgo,  Berlin,  pp.  SO,  90,  104, 


SURGICAL  INTERVENTION  457 

therapy  and  surgery  in  the  treatment  of  chronic  gastric 
ulcer,  Bamberger  arrives  at  the  following  conclusions: 

1.  The  end  results  of  internal  treatment  of  chronic 
gastric  ulcer  are  not  satisfactory,  but  the  same  is  true  of 
all  other  methods  of  treatment.  The  average  of  good 
permanent  results  amounts  to  70  per  cent.,  the  average  of 
failures  to  32  per  cent.,  including  both  early  and  late  mor- 
tality. Relapses  have  occurred  in  an  average  of  24.6  per 
cent,  of  all  cases  and  methods  of  treatment. 

2.  The  most  important  point  in  the  treatment  of  gastric 
ulcer  is  the  regulation  of  the  diet.  Lenhartz's  method  of 
administering  food  on  the  very  day  of  hemorrhage  is  con- 
traindicated,  if  the  stage  of  hemorrhage  is  still  present. 
The  treatment  during  that  stage  should  consist  in  giving 
the  stomach  the  greatest  possible  rest,  which  means  absten- 
tion from  all  food. 

3.  In  the  further  course  of  treatment,  Lenhartz's  dietary 
method  is  thoroughly  justified  and  advisable,  it  being  an 
established  fact  that,  after  cessation  of  bleeding,  the  patient 
will  not  be  injured  by  the  institution  of  this  treatment. 
Although  the  success  of  both  methods  of  treatment  is 
approximately  the  same,  the  fact  should  again  be  empha- 
sized that,  contrary  to  the  opinion  of  other  authors,  Len- 
hartz's procedure  is  not  better  in  bleeding  cases  (and, 
according  to  Bamberger's  experience,  it  is  even  less  valuable) 
than  that  of  Leube. 

4.  On  the  other  hand,  it  is  the  great  merit  of  Lenhartz 
to  have  demonstrated  that,  without  detriment  to  the  patient, 
Leube's  method  may  be  so  modified  after  cessation  of  the 
acute  hemorrhage  or  pain  period  that  fairly  large  quantities 
of  food  are  administered.  This  is  best  done  by  additional 
allowance  of  fat  in  the  form  of  butter,  cream,  eggs,  and 
sugar,  but  in  larger  quantities  than  has  so  far  been  prac- 
ticed in  following  Leube's  method. 

5.  The  average  number  of  failures,  amounting  to  32  per 
cent.,  proves  that  we  have  not  yet  a  method  of  treatment 
at  our  disposal  which  meets  all  requirements.     Until  such 


458  GASTRIC  ULCER 

has  been  found,  it  will  be  absolutely  necessary  to  bestow 
still  greater  care  upon  the  treatment  of  gastric  ulcer  than 
has  hitherto  been  done.  There  is  no  doubt  that  a  cure  can 
in  the  majority  of  cases  be  effected  if  the  treatment  is  logical 
and  persisted  in  for  a  sufficiently  long  time. 

6.  When  patients  who  have  been  operated  upon  for  ulcer 
are  discharged,  their  attention  should  be  called  to  the 
necessity  of  carefully  following  the  restful  diet  rules,  and 
furthermore  to  the  fact  that  even  slight  disorders  of  the 
stomach  must  be  heeded  and  properly  treated  lest  serious 
consequences  result. 

7.  While  the  treatment  of  chronic  gastric  ulcer  belongs 
to  the  domain  of  internal  medicine,  operative  intervention 
is  necessary  in  all  cases  which  defy  prolonged  and  repeated 
treatment  as  well  as  suitable  variations  of  method,  espe- 
cially in  patients  whose  capacity  for  work  is  heavily  handi- 
capped by  an  unmitigated  continuance  of  their  painful 
condition. 

8.  Operative  intervention  is  indicated  in  cases  which,  in 
spite  of  correct  and  repeated  treatment,  and  in  spite  of 
continued  complete  abstention  from  food,  cannot  be  cured — . 
cases  which  are  associated  with  persistent  violent  symptoms, 
hemorrhage,  vomiting,  and  emaciation. 

9.  Surgical  intervention  is  particularly  to  be  considered 
in  cases  of  pyloric  ulcer,  and  absolutely  indicated  if  internal 
treatment  has  proved  unsuccessful.  The  best  method  of 
operation  is  gastroenterostomy;  resection  should  only  be 
resorted  to  if  carcinomatous  degeneration  is  suspected. 
The  lethal  risk  to  which  patients  with  pyloric  ulcers  are 
exposed  by  operation  is  at  the  most  4  per  cent. 

10.  In  non-pyloric  ulcers  the  situation  is  totally  different, 
although  even  in  these  cases  surgical  intervention  is  to  be 
seriously  taken  into  consideration  after  internal  medicine 
has  failed,  even  though  the  mortality  following  operation 
for  gastric  ulcer  still  amounts  to  12.6  per  cent.  In  regard 
to  the  choice  of  operation,  preference  should  more  fre- 
quently be  given  to  the  radical  methods,  provided  the 
general  condition  of  the  patient  admits. 


SURGICAL  INTERVENTION  459 

11.  Adherence  to  a  proper  dietetic  regimen  is  more 
important  than  has  hitherto  been  assumed,  even  when  the 
operation  has  been  successful.  In  all  cases  it  is  advisable 
to  institute  a  rigorous  ulcer  cure  after  gastroenterostomy 
has  been  done. 

For  further  information  on  the  surgical  treatment  of 
gastric  ulcer,  the  reader  is  referred  to  the  chapter  on 
Surgical  Intervention. 


CHAPTER    XX 

GASTRIC  HEMORRHAGE— GASTRORRHAGIA 

Diagnosis. — The  diagnosis  of  gastric  hemorrhage  is  usually 
not  a  difficult  matter.  There  is,  as  a  rule,  hematemesis, 
accompanied  or  followed  by  melena.  Hemorrhages  from 
the  mouth  and  respiratory  tract,  in  which  the  blood  has  been 
carried  to  the  stomach  by  swallowing,  must  be  excluded. 
Due  inquiry  must  be  made  in  regard  to  possible  prior  and 
causative  injuries  to  the  head,  or  coincident  affections  of  the 
lungs.  In  gastrorrhagia  there  are  usually  some  circumstances 
which  indicate  the  exclusively  gastric  nature  of  the  trouble ; 
in  almost  every  instance  there  is  a  history  of  gastric  dis- 
turbance, often  of  long  duration,  preceding  the  hemorrhage. 
Hemorrhage  without  any  previous  symptoms  is  rare. 
Furthermore,  the  history  and  clinical  symptoms  render  the 
diagnosis  fairly  easy  as  to  the  particular  disease  causing 
the  hemorrhage,  whether  gastric  ulcer,  superficial  ulcera- 
tion, capillary  bleeding,  or  cancer.  Gastric  hemorrhage  has 
been  noted  by  Boas  in  the  following  conditions:  Venous  or 
varicose  hemorrhage  in  cirrhosis  of  the  liver  or  obstruction  to 
the  portal  circulation;  parenchymatous  gastric  hemorrhage 
in  diseases  of  the  heart,  liver,  or  blood;  acute  and  chronic 
gastritis;  stenosis  of  the  pylorus;  miliary  aneurism;  injury 
from  foreign  bodies  in  the  stomach;  caustic  poisons  in  the 
stomach;  jaundice  (cholemic  gastric  hemorrhage);  syphilis; 
arteriosclerosis;  septicemia;  rupture  of  abscesses  or  of  an 
aneurism  of  neighboring  structures  into  the  stomach; 
anemia  and  disturbances  of  menstruation  (vicarious  gastric 
hemorrhage);  hemorrhoids;  neurogenous  disturbances  (hys- 
teria, gastric  crises) ;  and  cholelithiasis. 

Gastric  ulcer  is  the  most  common  cause  of  hemorrhage 
from  the  stomach,  occurring  in  5  per  cent,  of  the  entire 


DIAGNOSIS  401 

population,  according  to  Ewald  and  others.  Hematemesis 
occurs  in  at  least  50  per  cent,  of  all  cases  of  gastric  ulcer, 
and  many  authorities  place  the  proportion  as  high  as  SO 
per  cent.  It  is  fatal  in  8  per  cent,  of  the  cases  in  which  it 
occurs,  according  to  the  conservative  estimate  of  Leube, 
and  we  cannot  question  that  it  is  indirectly  fatal  in  a  much 
greater  number  of  cases  through  anemia  and  its  remote 
consequences. 

Differential  Diagnosis. — The  differential  diagnosis  of 
doubtful  cases,  as  between  gastric  and  duodenal  hemorrhage, 
is  a  matter  fraught  with  greater  difficulty.  The  following 
symptoms  indicate  a  duodenal  origin  of  the  bleeding: 
(1)  Pain  about  one  to  three  hours  after  meals,  which  is 
relieved  by  the  taking  of  food;  (2)  considerable  melena, 
associated  with  hematemesis  or  existing  alone;  (3)  the  pain 
is  often  in  the  right  hypochondriac  region. 

Acute  hemorrhage  is  not  a  condition  that  lends  itself  to 
surgical  treatment.  It  can  usually  be  stopped  by  internal 
treatment;  and  if  this  should  fail,  operative  intervention 
is  not  likely  to  help.  Less  than  5  per  cent,  of  the  cases  die 
of  these  hemorrhages  without  operation.  By  subjecting 
patients  to  operation  we  expose  them  to  further  dangers, 
to  which  they  easily  succumb ;  while  without  operation  they 
have  a  reasonable  chance  to  recover.  This  view  is  shared  by 
a  large  number  of  experienced  surgeons.  As  a  matter  of 
fact,  few  cases  of  gastric  hemorrhage  have  been  lost  when 
proper  internal  therapeutic  measures  were  instituted.  With 
internal  treatment  Lenhartz  reports  201  cases  of  gastric 
hemorrhage  with  a  mortality  of  3  per  cent.,  Ewald  166  cases 
with  a  mortality  of  4.87  per  cent.,  and  Wirsberg  320  cases 
with  a  mortality  of  5.9  per  cent. 

The  recognition  of  gastric  hemorrhage  arising  from  ulcer 
is  usually  easy,  on  account  of  the  previous  diagnosis  of  the 
case ;  and  if  the  patient  is  seen  for  the  first  time  at  the  onset 
of  the  hemorrhage  or  later,  the  association  of  this  with  the 
other  classical  symptoms  of  ulcer,  particularly  pain  and 
vomiting  after  eating,  leaves  little  room  for  doubt.  \Miile 
there  may  be  pain,  vomiting,  and  gastrorrhagia  in  carcinoma 


462  GASTRIC  HEMORRHAGE— GASTRORRHAGIA 

of  the  stomach,  the  differences  that  distinguish  this  disease 
from  gastric  ulcer  are  so  marked  that  doubtful  or  border- 
line cases  are  rare. 

Prophylaxis. — Only  in  cases  in  which  the  diagnosis  is  ascer- 
tained with  certainty,  in  gastric  ulcer  or  carcinoma  in  which 
hemorrhage  may  be  anticipated,  are  prophylactic  measures 
likely  to  avail.  In  such  cases  occult  hemorrhages  frequently 
precede  hematemesis.  The  stools  should  be  examined  fre- 
quently for  occult  blood.  Boas  believes  that  concealed 
gastric  hemorrhage  is  of  very  frequent  occurrence,  not  only 
in  gastric  ulcer,  but  more  especially  in  carcinoma  of  the 
stomach,  in  which  the  patient  often  "bleeds  to  death,  as 
it  were,  by  drops,"  without  the  knowledge  of  the  physician. 
He  recommends  a  very  careful  analysis  of  the  feces  and 
gastric  contents  in  all  cases  in  which  there  is  the  least 
cause  for  suspicion;  the  patient,  meanwhile,  should  be  placed 
upon  a  meat-free  diet.  On  discovery  of  occult  blood  in  the 
stools  the  patient  should  be  placed  at  rest  in  bed;  the  diet 
should  be  exclusively  liquid,  preferably  milk,  the  quantity 
to  be  gradually  increased  until,  at  the  end  of  eight  days, 
three  liters  (quarts)  a  day  are  being  consumed.  It  may  be 
advisable  at  times  to  incorporate  gelatin  or  bismuth  with 
the  milk.  The  patient  should  maintain  the  recumbent 
posture  until  no  further  signs  of  hemorrhage  are  evident 
from  an  examination  of  the  stool. 

Treatment. — Visible  (manifest)  or  macroscopic  gastrorrhagia 
is  characterized  by  hematemesis,  tarry  stools  (melena),  or 
both.  In  the  treatment  of  this  condition  the  first  indication 
is  to  stop  the  bleeding;  the  second,  to  combat  the  condi- 
tion producing  the  hemorrhage.  The  patient  must  be  placed 
at  rest  in  bed,  in  the  dorsal  position.  An  ice  pack  suspended 
by  a  frame,  to  avoid  pressure,  is  placed  over  the  epigas- 
trium; this  will  have  an  analgesic  effect  and  conduce  to 
the  comfort  of  the  patient.  When  the  patient  is  suffering 
much  pain  and  is  very  restless  and  sleepless,  morphine 
hypodermically  will  often  bring  rehef.  Codeine  phosphate 
0.02  to  O.OG  Gm.  (|  to  1  grain)  or  dionin  0.02  to  0.03  Gm. 
(3  to  I  grain)  may  be  given  instead  of  morphine. 


T  lib:  AT  ME  ST   BY   LAVAGE  463 

Suppositories  of  extract  of  belladonna,  0.0075  (ini.  (| 
gi-ain),  and  extract  of  opium,  0.03  to  O.OG  Gm.  (^  to  1  grain), 
are  likewise  effective.  Absolute  abstinence  from  food  is  neces- 
sary, thus  keeping  the  stomach  at  rest  not  only  physically 
but  physiologically.  Thirst  is  to  be  counteracted  by  small 
pieces  of  ice  in  the  mouth  and  by  rinsing  the  mouth  with 
water.  Subcutaneous  injections  of  physiologic  salt  solution 
are  an  excellent  means  of  quenching  the  thirst.  It  is  rather 
doubtful  whether  nutrient  enemata  should  be  given  as  a 
prophylactic  measure  against  inanition  from  continuous 
hemorrhage.  Boas,  in  particular,  points  out  that  the 
giving  of  nutrient  enemata  always  causes  the  patient  to 
move  about  and  induces  lively  intestinal  peristaltic  motions. 
Bodily  movements  should  be  avoided.  Instead,  therefore, 
of  nutrient  enemata,  Boas  employs  proctoclysis,  or  pro- 
longed instillation  of  liquid  by  the  drop  method,  in  severe 
hemorrhage.  When  the  hemorrhages  are  moderate  in 
amount,  nutrient  enemata  may  be  resumed  earlier  than  in 
the  severer  cases.  While  the  hemorrhage  is  in  progress 
the  ice  bag  should  be  replaced  by  a  Priessnitz  bandage. 
Hot  compresses  should  not  be  employed  after  recent  hem- 
orrhages. 

Should  the  quantity  of  blood  lost  be  large,  normal  saline 
must  be  administered  by  subcutaneous  or  intravenous 
injection. 

Treatment  by  Lavage. — A  number  of  writers,  among  whom 
is  Ewald,  recommend  lavage  of  the  stomach  with  ice  water 
to  remove  clots  and  at  the  same  time  to  act  as  a  styptic. 

Gastric  lavage,  says  Kaufmann,^  is  the  most  expedient 
means  in  the  treatment  of  severe  hemorrhage  from  gastric 
ulcer,  provided  it  be  carefully  applied.  It  relieves  over- 
distention  by  removing  the  stagnating  masses  of  accumu- 
lated blood,  acid  secretions,  food  remnants,  and  gas, 
which  are  usually  present  in  such  cases,  and  which  not 
only  give  rise  to  nausea  and  pain,  but  act  as  a  constant 
source   of   irritation   to  the  mucous  membrane,   inducing 

1  The  Treatment  of  Hemorrhage  from  Gastric  Ulcer,  American  Journal 
of  the  Medical  Sciences,  June,  1910. 


464  GASTRIC  HEMORRHAGE— GASTRORRHAGI A 

hypersecretion  and  thus  increasing  the  amount  of  gas- 
tric contents.  The  removal  of  this  material  allows  the 
emptied  stomach  to  contract,  and  this  aids  in  the  occlu- 
sion of  the  eroded  vessel.  Kaufmann  believes  that  the 
thrombus  ordinarily  formed  does  not  usually  fill  the  open- 
ing of  the  bloodvessel  completely.  Lavage  removes  such 
inefficient  thrombi  and  gives  the  bleeding  vessel  a  chance 
to  contract  and  form  a  more  efficient  thrombus.  With  a 
carefully  performed  lavage  there  should  be  no  danger  of 
causing  perforation  by  overdistention;  the  amount  of  water 
in  the  stomach  at  any  one  time  should  be  comparatively 
small,  and  if  perforation  from  the  pathologic  process  should 
occur  the  cleansing  of  the  stomach  will  prove  beneficial, 
since  it  prevents  the  gastric  contents  from  entering  the 
peritoneum.  It  is  well  known  that  the  prognosis  in  perfora- 
tion is  far  better  when  the  perforation  takes  place  at  a 
time  when  the  stomach  is  empty. 

The  patient  being  in  the  recumbent  position,  the  tube 
should  be  inserted  far  enough  to  secure  siphonage,  and  about 
300  Cc.  (§x)  of  water  used  at  a  single  lavage.  The  removal 
of  digesting  and  decomposing  blood  from  the  stomach  tends 
strongly  to  prevent  vomiting  and  distress,  and  places  the 
stomach  at  rest. 

After  lavage,  large  doses  of  crystalline  bismuth  subnitrate 
should  be  administered.  Bismuth  in  crystalline  form  is 
supposed  to  adhere  more  tenaciously  to  the  surface  of  the 
ulcer  than  the  ordinary  amorphic  form,  so  that  the  blood 
is  agglutinated  to  the  bismuth  mass.  Bismuth  is  not 
sufficiently  astringent  to  contract  the  bloodvessels  and 
thereby  stop  the  hemorrhage;  it  does,  however,  aid  in  the 
coagulation  of  the  blood,  at  the  same  time  exercising  a 
soothing  influence  upon  the  gastric  mucous  membrane. 

The  objection  to  the  introduction  of  the  tube  into  the 
stomach  in  the  presence  of  gastric  ulcer  has  induced 
Bourget  to  prepare  an  iron-chloride  gelatin,  although  he 
reports  no  untoward  effects  due  to  the  tube.  This  iron 
gelatin  compound  is  prepared  as  follows:  100  Gm.  of  gelatin 
is  dissolved,  with  the  aid  of  moderate  heat,  in  100  Gm. 


TREATMENT  BY  LAVAGE  465 

water  and  100  Gm.  glycerin.  After  complete  liquefac- 
tion, 50  Gm.  of  tincture  chloride  of  iron  is  rapidly  added 
to  the  liquid.  Coagulation  now  takes  place,  with  the  forma- 
tion of  a  precipitate,  which  mixes  with  difficulty  with  the 
remainder  of  the  fluid.  The  entire  mass  is  gradually  heated 
and  is  stirred  constantly  until  it  becomes  homogeneous. 
It  is  then  poured  upon  metal  plates  which  are  subdivided 
into  small  squares  (one  centimeter).  The  cooled  mass 
keeps  very  well.  Two  or  three  tablets  are  administered 
daily,  two  to  three  hours  after  meals,  to  patients  suffering 
from  ulcer. 

Bourget   prescribes  the  following   diet  in  gastric  hemor- 
rhage : 


8  A.M.     Milk  and  rusks. 

10  A.M.     Chloride-of-iron  gelatin. 
10.30  A.M.     100  to  1.50  Cc.  alkaline  water  (Bourget's  alkaline  water 
contains  8  Gm.  sodium  bicarbonate,  4  Gm.  sodium 
phosphate  and  2  Gm.  sodium  sulphate  in  each  liter). 
12  M.         Milk  rice. 
3  P.M.     Chloride-of-iron  gelatin. 
3.30  to  4  P.M.     150  Cc.  alkaline  water. 
6  P.M.     Milk  rice. 

9  P.M.     Chloride-of-iron  gelatin. 

10  P.M.      100  to  1.50  Cc.  alkaline  water. 


The  results  of  this  treatment  are  usually  good.    The  pains 
soon  cease,  and  cicatrization  of  the  ulcer  takes  place. 

In  cases  of  severe  hemorrhage  Bourget  commences  the 
treatment  by  washing  the  stomach  with  a  1-per-cent. 
chloride-of-iron  solution,  and  then  administers  only  the 
gelatin.  In  his  cases  this  treatment  resulted  in  an  immediate 
and  permanent  cessation  of  the  hemorrhage.  Experiments 
made  in  test-tubes  have  shown  that  the  chloride  of  iron 
gelatin  is  gradually  digested,  that  is,  becomes  liquefied, 
under  the  action  of  pepsin  and  hydrochloric  acid.  This 
digestion  is  not  immediate — a  certain  length  of  time  is 
required  to  accomplish  it.  In  the  stomach  the  gelatin 
squares  probably  come  in  contact  with  the  ulceration  and 
there  exert  their  cicatrizing  effect. 
30 


466  GASTRIC  HEMORRHAGE— GASTRORRHAGI A 

Treatment  by  Enemata. — Hot  water  enemata  have  been 
employed  with  favorable  results.  The  enema  consists  of 
one-half  liter  (one  pint)  of  water  at  120°  F.;  this  should  be 
given  three  times  a  day.  The  object  is  to  produce  reflex 
anemia  in  the  upper  portions  of  the  intestine. 

In  several  cases  which  had  resisted  all  the  usual  medicinal 
and  dietetic  treatment,  Tripier  secured  prompt  and  lasting 
results  by  hot  enemata  repeated  twice  and  thrice  daily. 
The  water  should  be  injected  at  a  temperature  of  112° 
to  120°  F.  There  can  be  no  doubt,  he  says,  that  in  these 
cases  the  hemorrhage  came  from  the  stomach,  duodenum, 
and  points  high  up  in  the  ahmentary  tract.  Hot  water  acts 
reflexly.  Tripier  has  also  found  that  hot  enemata  promptly 
check  intestinal  hemorrhage  in  typhoid  fever,  as  they  do 
bleeding  from  the  rectum,  sigmoid,  and  large  intestine. 
We  use  hot  water  to  check  external,  uterine,  and  other 
hemorrhages;  and  so  superior  is  it  to  ice  that  it  has  almost 
entirely  supplanted  it.  It  certainly  should  be  preferred  in 
rectal  and  other  intestinal  hemorrhages  where  the  water 
can  come  promptly  in  contact  with  the  bleeding  points. 
We  also  know  that,  with  the  patient  in  proper  position, 
points  higher  up  in  the  alimentary  canal  may  thus  be 
reached  and  the  bleeding  capillaries  or  arterioles  influenced 
directly  by  the  best  of  hemostatics — heat.  There  is  also 
evidence  to  show  that  it  acts  reflexly,  and  may  in  this  way 
control  duodenal  and  even  gastric  hemorrhage.  Plunging 
the  hands  into  hot  water  will  at  times  quickly  arrest  bleed- 
ing at  the  nose,  as  will  also  ice  applied  to  the  head.  This 
surely  must  be  reflex.  Another  and  good  reason  for  using 
hot  water  per  rectum  in  the  manner  advised  by  Tripier  is 
that,  if  nothing  more  be  done,  shock  is  combated  in  the  best 
possible  way,  as  it  is  easy  to  add  sodium  chloride  to  the 
water  in  proper  proportion  to  make  normal  salt  solution. 

Efforts  have  been  made  to  effect  a  reflex  contraction  of 
the  gastric  arterioles  by  introducing  ice  into  the  rectum. 

Medicinal  Treatment. — Hemostatics. — Ergot  has  a  direct 
hemostatic  action  when  taken  internally.  The  following 
prescriptions  have  been  found  useful: 


MEDICINAL  TREATMENT  467 

Ciin.  or  Cc. 

^ — Extract i  orgota? 1.0  nr.  ,\v 

Aqua- (lostillatiy 5.0  ITllxxv 

Phenolis  liquefacti    .  0.06  Tllj 

Misce. 

Sig. — Fifteen  minims  to  be  injected  subcutunoously.     (Boas.) 

Gm.  or  Cc. 

I^— Extracti  ergotse 2.5  gr.  xxxviiss 

Glycerini, 

Aqua; aa        5.0  TTllxxv 

Misce. 

Sig. — Fifteen  minims  several  times  daily,  hyijodermically.     (Wegele.) 

Hydrastine  hydrochloride  is  less  effective: 

Gm.  or  Cp. 

I^ — Hydrastinse  hj'drochloridi 0.5  gr.  Aaiss 

Aquae 4.0  3j 

Misce. 

Sig. — Fifteen  to  thirty  minims  hypodermically. 

The  employment  of  gelatin  is  more  promising.  Sterile 
gelatin  is  furnished  by  Merck  in  strengths  of  10  per  cent, 
and  20  per  cent.  It  is  marketed  in  sealed  glass  tubes, 
ready  for  use,  and  is  liquefied  by  placing  the  tubes  in  hot 
water.  It  is  then  taken  up  by  means  of  a  large  syringe 
directly  from  the  glass  tube,  and  injected  subcutaneously: 
40  Cc,  containing  gelatin  10  per  cent.,  constitutes  a  single 
dose  for  adults;  in  obstinate  cases  this  may  be  repeated 
several  times.  Strict  antiseptic  precautions  must  be 
observed  in  this  method  of  medication.  When  Merck's 
gelatin  cannot  be  obtained,  a  1  to  2  per  cent,  gelatin  solu- 
tion may  be  prepared  with  physiologic  salt  solution.  This 
is  then  sterihzed  carefully,  and  introduced  under  the  skin 
by  means  of  a  syringe. 

The  internal  administration  of  gelatin  in  the  following 
form  is  recommended  for  the  treatment  of  gastric  and 
intestinal  hemorrhage:^ 

1  Journal  de  medecine  de  Paris,  January  16,  1909. 


468  GASTRIC  HEMORRHAGE— GASTRORRHAGI A 

Gm.  or  Cc. 

I^— Gelatini 20.0  5v 

Acidi  citrici 2.0  gr.  xxx 

Syrupi  aurantii 20.0  ov 

Aquse,  q.  s. 
Boil  the  gelatin  with  water  for  six  hours  until  it  is  completely  liquefied, 
then  add  sufficient  water  to  make  200  Cc.  (7  ounces).    Cool,  filter,  and  add 
the  citric  acid  and  syrup  of  orange. 

Sig. — One  or  two  tablespoonfuls  to  be  taken  every  two  hours. 

The  injection  of  home-made  gelatin  solutions  is  always 
fraught  with  danger  because  of  the  possibility  of  infection. 
Besides,  the  injections  are  painful. 

A  1  to  2  per  cent,  gelatin  solution  may  be  administered 
as  an  enema.  Hot  5-per-cent.  gelatin  solutions  have  been 
given  per  rectum  with  advantage  in  doses  of  250  to  1000  Cc. 
(^  pint  to  2  pints)  two  to  four  times  daily.  These  rectal 
injections  have  to  be  made  in  such  a  manner  as  not  to 
interfere  with,  the  perfect  quiet  of  the  patient.  Occasionally 
it  is  well  to  elevate  the  foot  of  the  bed. 

The  action  of  gelatin  is  supposed  to  be  due  to  its  Hme 
salts;  lime  acts  as  a  hemostatic.  In  severe  hemorrhages 
chloride  of  lime  has  been  emploj^ed  by  Boas  in  5  to  10  per 
cent,  solution  in  the  form  of  small  rectal  enemata — 10  to 
12  Cc. — every  two  to  three  hours.  Wright  recommends 
calcium  lactate,  to  be  administered  by  mouth,  1  to  2  Gm. 
(15  to  30  grains)  three  times  a  day.  It  may  be  adminis- 
tered hypodermically  in  the  same  doses. 

Another  preparation  of  Merck's  is  stypticin,  which  is 
injected  in  10-per-cent.  watery  solution,  subcutaneously 
(15  to  30  minims  three  times  a  day).  Good  results  have  been 
claimed  for  it. 

According  to  Riegel,  subcutaneous  injections  of  atropine 
have  produced  favorable  results,  though  the  drug  is  not 
directly  hemostatic;  the  effect  is  due  to  its  inhibitory 
action  on  the  secretions.  The  hemorrhagic  blood  effused 
into  the  stomach  acts  as  a  stimulus  to  the  secretion,  and 
thus  the  coagula  closing  up  the  bleeding  vessels  are  con- 
stantly redissolved  by  the  gastric  juice;  if  atropine,  by  sup- 
pressing  the   secretion,    prevents   the    thrombotic    coagula 


MEDICINAL   TREATMENT  469 

from  being  dissolved,  it  may  be  said  to  act  indirectly  as  a 
hemostatic  agent. 

Clinicians  of  wide  experience,  as  Boas  and  Riegel,  reiterate 
their  objection  to  the  internal  administration  of  styptics, 
and  permit  only  the  administration  of  10-per-cent.  gelatin, 
one  tablespoonful  every  hour,  which  forms  thrombi  in  the 
bleeding  vessels. 

Adrenalin  (Parke,  Davis  &  Co.)  and  other  preparations 
of  the  suprarenal  gland  are  recommended,  in  solutions  of 
1  to  1000,  15  to  30  drops  by  mouth,  two  or  three  times,  at 
short  intervals,  the  day  of  the  hemorrhage.  These  prepara- 
tions are  not  all  of  equal  value;  a  reliable  brand  should  be 
selected. 

Halderman^  describes  the  satisfactory  treatment  of  a 
case  of  gastric  hemorrhage  with  adrenalin.  The  patient 
was  a  man,  aged  sixty-five  years,  whose  condition  was 
most  serious.  He  was  in  a  cold,  clammy  perspiration,  radial 
pulse  imperceptible,  and  with  every  appearance  of  impending 
dissolution.  He  was  given  10-drop  doses  of  solution  adren- 
alin chloride  1  to  1000,  every  thirty  to  sixty  minutes,  until 
he  had  taken  one  drachm  of  the  solution.  The  vomiting 
and  hemorrhage  soon  stopped,  and  for  three  weeks  rectal 
alimentation  was  depended  upon;  he  was  given,  per  rectum, 
one  pint  of  normal  salt  solution  daily,  with  instructions  to 
retain  it  if  possible,  which  was  usually  done. 

In  collapse  after  profuse  hemorrhage,  caffeine  may  be 
given : 

Gm.  or  Cc. 

I^ — Caffeinse  sodio-salicylatis 4.0  5i 

Aquae ad       40.0  ox 

Misce. 

Sig. — Fifteen  to  thirty  minims  hypodermically.     (Wegele.) 

When  the  hemorrhage  has  ceased  for  several  days  and 
examination  of  the  feces  show^s  a  complete  cessation  of 
occult  bleeding,  the  administration  of  more  copious  nutrient 
enemata  is  indicated.  Feeding  by  mouth  may  now  be  begun. 
The    quantity   of   milk    should   be   gradually   and   slowly 

^  Cincinnati  Lancet-Clinic. 


470  GASTRIC  HEMORRHAGE— GASTRORRHAGI A 

increased,  so  that  about  one  liter  (quart)  will  be  consumed 
on  the  eighth  day  after  the  cessation  of  the  hemorrhage. 
When  hemorrhage  is  due  to  the  presence  of  gastric  ulcer, 
the  ''Leube  cure"  or  ''Lenhartz  cure"  may  be  instituted 
at  this  period. 

The  ''Leube"  and  ''Lenhartz"  dietetic  methods  of  treat- 
ment for  gastric  ulcer  in  which  hemorrhage  is  a  complica- 
tion have  been  described  (Chapter  XIX).  Lenhartz  amis 
at  maintaining  the  nutrition  of  the  patient  at  the  highest 
possible  point,  while  at  the  same  time  he  avoids  overdisten- 
tion  of  the  stomach  by  food.  The  protein  content  of  his 
diet  serves  to  counteract  the  hyperacidity  when  the  case 
is  one  of  ulcer  wdth  hemorrhage  as  a  complication. 

Drugs,  as  a  rule,  play  a  subordinate  part  in  the  treatment 
of  hemorrhage  from  gastric  ulcer,  especially  when  proper 
dietetic  treatment  can  be  instituted  and  carried  out.  When, 
however,  patients  must  be  treated  while  following  their 
usual  occupations,  or  when  pains  persist  in  spite  of  dietetic 
measures,  medication  proves  especially  valuable. 

Bismuth  in  the  form  of  one  of  its  salts  is  employed  prob- 
ably more  extensively  than  any  other  drug  in  the  treatment 
of  hemorrhage  of  the  stomach.  Its  use  was  originally 
suggested  by  Kussmaul  and  Fleiner.  The  subnitrate  of 
bismuth  was  at  one  time  used  almost  exclusively;  but 
reports  of  several  cases  where  slight  toxic  effects  were 
manifest  led  to  the  substitution  of  bismuth  subcarbonate. 
The  bismuth  salts  owe  their  efficacy  to  their  slightly  astrin- 
gent effect,  which  promotes  granulation  at  the  surface  of 
the  ulcer.  Animal  experimentation  has  shown  that  bis- 
muth stimulates  the  secretion  of  mucus,  which,  together 
with  the  salt  itself,  forms  a  protective  film  upon  the  denuded 
portions  of  the  gastric  mucous  membrane.  This  covering 
is  capable  of  protecting  the  ulcerated  points  from  irritation 
by  both  food  and  gastric  juice.  The  bisnuith  meanwhile 
becomes  oxidized,  changing  into  the  dioxide  of  bismuth. 
Under  this  bismuth  coating  the  formation  of  granulation 
tissue  can  proceed  without  interruption,  resulting  in  the 
so-called  bismuth  eschar.     Since  the  bismuth  preparations 


MEDICI.XAL   TREATMENT  471 

are  astringent  they  diminish  secretion,  mitigate  the  severity 
of  pain,  and  arrest  hemorrhage. 

The  bismuth  salts,  however,  have  their  drawbacks  as 
therapeutic  agents  in  gastric  hemorrhage.  In  addition  to 
the  toxic  effects  sometimes  manifest,  which  are  fortunately 
of  rare  occurrence,  the  salts  of  bismuth  tend  to  cause  con- 
stipation. ]Many  stomachs  show  a  marked  intolerance  for 
large  doses  of  this  drug.  At  times  the  bismuth  eschar 
becomes  so  firmly  attached  to  the  surface  of  the  ulcer  as  to 
prevent  free  drainage  of  the  wound  secretions. 

Fleiner  has  recommended  thorough  lavage  of  the  stomach 
before  the  administration  of  bismuth.  Bismuth  sub- 
nitrate,  10  to  12  Gm.  (oiiss-iij),  in  a  glass  vessel  con- 
taining 200  Cc.  (§vij)  of  lukewarm  water,  is  permitted  to 
enter  the  stomach  through  the  stomach  tube.  A  clamp  is 
then  applied  to  the  upper  end  of  the  tube,  and  when  time 
has  been  allowed  for  the  precipitation  of  the  heavy  bismuth 
salt  onto  the  walls  of  the  stomach  the  water  is  drawn  off 
comparatively  clear.  The  patient  assumes  various  postures 
during  the  precipitation  of  the  bismuth,  which  favor  the 
coating  of  the  site  of  the  ulcer.  The  bismuth  suspension 
is  used  at  first  every  day,  later  every  second  day,  and  finally 
every  third  day  until  all  symptoms  of  irritation  have  ceased. 
In  the  presence  of  hemorrhage  the  tube  should  not  be  intro- 
duced so  frequently.  The  patient  may  drink  the  bismuth 
mixture  after  a  cleansing  process,  which  consists  of  par- 
taking of  150  Cc.  (5v)  of  Carlsbad  water  an  hour  before  the 
bismuth  is  to  be  administered.  Bismutose,  an  albuminous 
bismuth  preparation  (21  per  cent,  bismuth),  may  be  em- 
ployed instead  of  the  bismuth  salts. 

Some  clinicians  combine  Cohnheim's  oil  cure  with  the 
bismuth  treatment,  in  the  form  of  a  suspension  of  bismuth 
in  oil. 

Good  results  have  been  reported  from  the  use  of  chalk 
and  talcum,  each  two  parts,  to  magnesium  oxide,  one  part. 
The  dose  is  one  heaping  teaspoonful,  suspended  in  water, 
three  times  a  day. 

One  of  the  most  recent  hemostatics  for  the  treatment  of 


472  GASTRIC  HEMORRHAGE— GASTRORRHAGI A 

gastric  hemorrhage  is  escalin,  introduced  by  G.  Klemperer. 
This  is  a  paste  of  finely  powdered  aluminum  in  glycerin, 
and,  according  to  Klemperer,  it  possesses  the  property  of 
arresting  bleeding  more  effectually  than  other  means. 
Klemperer  gives  the  following  directions  for  its  use:  Immedi- 
ately after  the  occurrence  of  hemorrhage  the  patient  takes 
four  tablets  of  escalin  (altogether  10  grammes  of  alumi- 
num), crushed  and  suspended  in  a  glass  of  water.  Then 
he  abstains  from  food  for  a  day,  taking  only  small  pieces 
of  ice.  Transfusion  of  normal  salt  solution  is  indicated 
in  case  of  severe  anemia  from  hemorrhage.  The  next  morn- 
ing four  tablets  of  escalin,  suspended  in  100  Cc.  (Biij)  of 
cold  milk,  are  given  during  one  to  two  hours.  The 
same  procedure  is  followed  on  the  third  day.  On  the 
fourth  day  escalin  is  given  for  the  last  time.  The  patient 
is  now  placed  upon  a  more  liberal  diet,  consisting  of  softened 
zwieback  and  yolk  of  egg  in  milk.  From  the  fifth  day 
mashed  potatoes  are  added  to  the  dietary,  and  a  mixed  diet 
is  gradually  resumed.  Occasionally  Klemperer  permits 
small  quantities  of  milk  even  on  the  first  day;  on  the  third 
day  yolk  of  egg  and  zwieback;  on  the  fifth  day  finely  chopped 
meat. 

It  has  been  found  that  escalin  stimulates  the  secretion 
of  gastric  juice,  and  the  general  conclusion  has  been  that 
it  is  not  able  to  combat  hemorrhage  more  quickly  than 
either  Leube's  or  Lenhartz's  methods.  It  would  appear, 
therefore,  that  the  administration  of  escalin  cannot  be  con- 
sidered as  a  valuable  addition  to  the  therapeutic  measures 
at  our  disposal  for  arresting  hemorrhages  of  the  stomach. 

Silver  nitrate  is  similar  in  its  action  to  bisnuith.  In  the 
treatment  of  conditions  associated  with  gastric  hcmori'hage, 
Boas  commences  with  a  solution  of  0.25  Gm.  (4  grains)  in 
120  Cc.  (4  ounces)  of  distilled  water,  one  tablespoonful  to 
be  taken  three  times  a  day  when  the  stomach  is  empty. 
The  strength  of  the  solution  is  gradually  increased  to 
0.3  Gm.  in  120  Cc.  The  stronger  solution  should  be  con- 
tinued for  five  days.  Finally,  a  solution  of  0.4  Gm.  to  120  Cc. 
(6  grains  in  4  ounces)  is  taken,  the  dose  being  the  same  as 


MEDICINAL  TREATMENT  473 

before   (one  tablespoonful).     In  the  meantime  the  Leube 
method  of  treatment  should  be  followed. 

Analgesics. — Analgesic  drugs,  such  as  morphine,  dionin, 
codeine,  extract  of  belladonna,  may  be  administered  with 
bismuth  powders: 

Gm.  or  Cc. 

I^ — Codeinse  phosphatis 0 .  03  gr.  ss 

Extract!  belladonna'  0.02  gr.  3 

Bismuthi  subnitratis 0.60  gr.  x 

Misce  et  ft.  pulv.  no.  i,  mitte  x. 

Sig. — One  three  or  four  times  a  day. 

Atropine  has  been  employed  with  advantage  in  the  treat- 
ment of  gastric  hemorrhage  due  to  slow-healing  ulcers, 
with  h}T)eracidity,  hypersecretion,  and  motor  disturbances. 
Tabora,  who  was  the  first  to  advocate  the  use  of  atropine 
in  these  conditions,  begins  his  treatment  with  a  period  of 
several  days'  abstinence  from  food  by  mouth.  Fluids  only 
are  administered,  and  they  by  rectum.  After  this  initial 
period  (varying  in  length  according  to  the  condition  of  the 
patient)  has  passed,  the  patient  is  given  one  tablespoonful 
of  milk  every  hour.  This  quantity  is  increased  to  50  Cc. 
(5xij),  then  to  100  Cc.  (§iij),  and  to  200  Cc.  (§vij)  with 
one-third  cream,  so  that  by  the  end  of  two  weeks  the  patient 
has  attained  a  condition  of  calorific  eciuilibrium.  This  milk- 
cream  diet  is  continued  for  at  least  four  weeks,  when  gruel 
or  eggs  should  be  added.  At  the  beginning  of  treatment 
patients  are  given  one  milligramme  (eV  grain)  of  atropine 
sulphate  hypodermically  morning  and  night.  If  required, 
however,  3  to  4  milligrammes  (217  to  tV  grain)  may  be  admin- 
istered daily.  Atropine,  owing  to  its  effect  upon  hyperse- 
cretion, has  a  marked  influence  on  pain.  Its  administration 
may  be  continued  for  four  to  eight  weeks.  The  chief  unto- 
ward effects  complained  of  by  patients  .are  dryness  of  the 
mouth  and  indistinct  vision  resulting  from  the  cycloplegic 
action  of  the  drug.  Tabora  ascribes  the  favorable  results 
from  the  use  of  atropine  to  its  inhibitory  action  upon 
gastric  secretion  and  its  antispasmodic  effect. 

Chloroform  water  (1  to  120),  one   tablespoonful   every 


474  GASTRIC  HEMORRHAGE— GASTRORRHAGIA 

two  hours,  may  be  given  when  sHght  pains  are  present. 
Chloroform  may  be  prescribed  in  combination  with  bis- 
muth also: 

Gm.  or  Cc. 

I^ — Chlorofornii 1.0  n\xv 

Bismuthi  subnitratis 3.0  gr.  xlv 

Aquae q.  s.  ad     150.0  gv 

Misce. 

Sig. — One  tablespoonful  to  be  taken  every  hour. 

Schleich  has  introduced  a  new  preparation  of  chloroform, 
which  he  designates  desalgin.  He  succeeded  in  combining 
chloroform  permanently  up  to  25  per  cent,  with  an  albumin- 
ous substance.  From  this  he  obtained  a  gray  amorphous 
powder,  which  represents  a  colloidal  chloroform  in  solid 
form,  and  which  has  proved  effectual  as  an  analgesic  in  all 
painful  conditions  of  the  abdominal  organs,  especially  the 
stomach.  The  dose  is  0.3  Gm.  (5  grains)  three  or  four 
times  a  day. 

Cocaine  may  be  made  use  of  in  the  presence  of  pain  and 
obstinate  vomiting. 

Orthoform  and  anesthesin  are  more  recent  analgesic 
remedies.  The  prompt  effect  of  orthoform  in  relieving  the 
pain  of  ulcer  associated  with  hemorrhage  has  been  noted. 
Orthoform  acts  through  its  paralyzing  effect  on  the  periph- 
eral sensory  nerve-endings.  It  is  a  derivative  of  oxybenzoic 
acid.  Anesthesin  has  the  same  effect  as  orthoform.  (See 
p.  194.) 

Lenhartz  recommends  the  following  pill  in  the  treatment 
of  the  severe  anemias  resulting  from  gastric  hemorrhage: 

(im.  or  Cc. 

I^ — Ferri  suIpliiitLs, 

Potassii  carl)onatis aa       15.0  5ss 

Tragacantha',  q.  s. 
Misce  et  ft.  pil.  no.  c. 
Sig. — Three  i)ill.s  three  tiine.s  a  day. 

Iron  in  this  form  is  sometimes  badly  borne,  which  fact 
has  led  to  the  inti-oduction  of  other  iron  ])reparati()ns. 
Rodari   endorses    ferratin,    a   preparation    said    to   contain 


MEDICINAL   TREATMENT  475 

6  per  cent,  of  iron  combined  in  such  a  way  as  to  render  it 
directly  absorbable.  Triferrin  (Knoll)  is  another  prepara- 
tion of  iron  foi-  which  much  has  been  claimed.  Fersan  has 
been  described  on  page  107.  I  prefer  the  hypodermic 
administration  (see  p.  240). 

As  a  tonic  and  hematinic  for  the  relief  of  the  anemic 
and  emaciated  condition  of  the  patient  the  following  may 
be  prescribed: 

Gm.  or  Cc. 

I^ — Ferri  sulphatis  exsiccati 0.06  gr.  j 

Mangani  dioxidi, 

Quinina^  bisulphatis aa       0.1  gr.  iss 

Extracti  nucis  vomicte 0.01  gr- I 

Extract!  gentiame 0.14  gr.  ij 

Misee  et  ft.  caps.  no.  i,  mitte  1. 

Sig. — One  four  times  daily. 

As  a  hematinic  Ewald  recommends  a  2  to  3  per  cent, 
solution  of  the  sesquichloride  of  iron,  one  teaspoonful  three 
times  a  day  in  a  wineglass  of  egg  water.  The  egg  water, 
an  albumin  solution,  is  made  by  adding  one  part  of  egg 
albumin  to  two  parts  of  water. 

Some  authors  recommend  a  combination  similar  to  the 
following  in  cases  of  gastric  hemorrhage: 


I^ — Acidi  tannici 

Glycerini 

Aquse  destillatse        .      .      .      .       q.  s.  ad 
Misce. 
Sig. — To  be  taken  at  one  dose. 

Or, 


I^ — Bismuthi  subcarbonatis 

Pulveris  ti'agacantha? 

Acidi  hydrocyanic!  diluti 

Liquoris  morphinse  hydrochloridi  (1%) 

Aquae  chloroformi  q.  s.  ad 

Misce. 
Sig. — At  one  dose,  and  repeat  three  times  a  day 


Gm.  or  Cc. 

2.0 

gr.  XXX 

2.0 

lllxxx 

30.0 

5i 

Gm.  or  Cc. 

0.75 

gr.  xij 

0.30 

gr.  V 

0.30 

TIlv 

0.65 

mx 

15.0 

5ss 

476  GASTRIC  HEMORRH AGE—GASTRORRH AGI A 

Hyperchlorhj^dria  not  infrequently  precedes  gastric  hem- 
orrhage. To  counteract  this  condition,  bismuth  subnitrate 
is  recommended  in  large  doses  after  meals,  wrapped  in 
wafers  or  suspended  in  mucilage.  The  following  combina- 
tion is  of  value: 

Gm.  or  Cc. 

I^ — Sodii  bicarbonatis 0 .  50  to  1 . 0             gr.  ^aij-v  x 

^lagnesii  oxidi 0.65                        gr.  x 

Bismuthi  subnitratis      ....  1 .  30                        gr.  xx 

Cretse  prEeparatse 0 .  25                        gr.  iv 

Misce  et  ft.  chart,  no.  i,  mitte  xx. 

Sig. — One  powder  after  each  meal. 

Constipation  may  occur  with  the  administration  of  the 
foregoing,  and  under  such  circumstances  a  saline  laxative 
would  be  indicated. 

Operative  Treatment. — If  energetic  internal  treatment  should 
not  be  successful  in  checking  chronic  oozing  of  blood — 
as  can  easily  be  observed  by  daily  examination  of  the  feces 
with  the  benzidin  test  for  occult  blood — operative  treat- 
ment should  be  advised.  Either  resection  of  the  ulcer,  or, 
where  this  is  impossible,  gastroenterostomy,  should  be 
performed.  The  latter  operation  frequently  stops  the  hem- 
orrhage, especially  if  the  ulcer  be  situated  at  the  pylorus. 
In  pyloric  ulcer,  however,  it  is  not  the  hemorrhage,  but  the 
stenosis,  which  renders  operation  necessary.  In  cases  which 
do  not  improve  after  a  prolonged  course  of  internal  treat- 
ment, and  pyloric  obstruction  is  not  present,  it  is  unwise 
to  promise  a  recovery  by  means  of  gastroenterostomy. 
Surgeons  agree  that  good  results  from  gastroenterostomy 
in  ulcer  of  the  stomach  are  obtained  only  when  there  is  a 
pyloric  obstruction.  The  operation  does  not  afford  drain- 
age and  physiologic  rest  when  the  pylorus  is  patulous; 
Cannon  and  others  have  shown  that  food  and  liquids  pass 
through  the  pylorus  even  after  gastroenterostomy  has  been 
performed.  The  artificial  opening  does  not  help  matters 
so  long  as  the  pylorus  is  unobstructed  (see  p.  208). 


CHAPTER    XXI 

EROSIONS— PERIGASTRITIS 
EROSIONS  OF  THE  STOMACH 

Forms. — Acute  or  Hemorrhagic  Erosions. — These  are  small 
abrasions  of  the  gastric  mucosa  which  extend  partly  through 
this  layer.  They  are  usually  multiple.  They  occur  in  the 
newborn;  in  chronic  diseases  of  the  heart  or  arteries;  accord- 
ing to  Dieulafoy,  in  acute  infections  with  the  pneumococcus; 
and  in  septic  infection.  Hemorrhagic  erosions  of  the  gastric 
mucous  membrane  are  sometimes  complications  of  chronic 
gastritis  in  its  early  stages. 

Pain  in  this  condition  is  best  relieved  by  lavage  with  a 
0.5-per-cent.  solution  of  nitrate  of  silver,  after  rinsing  out 
the  fasting  stomach  with  lukewarm  water.  The  silver 
solution  should  be  permitted  to  remain  in  the  stomach  for 
about  a  minute;  on  its  removal  the  lavage  is  repeated 
with  lukewarm  normal  salt  solution.  This  treatment  may 
be  employed  every  other  day  for  ten  or  twelve  days,  or  until 
all  particles  of  mucous  membrane  have  disappeared  from  the 
stomach  contents. 

Chronic  Erosions  of  the  Stomach. — Einhorn,  who  was  the 
first  to  describe  gastric  erosions  as  a  clinical  entity,  defines 
the  condition  as  one  in  which  the  gastric  mucous  membrane 
becomes  the  seat  of  small  superficial  exfoliations. 

Gerhardt  describes  erosions  of  the  stomach  as  follows: 
''Sections  made  of  erosions  show,  as  a  rule,  that  at  the  base 
of  the  ulcerations  almost  the  entire  lower  half  of  the  mucous 
membrane  is  still  preserved.  In  the  epithelium  of  these 
remaining  glands  nothing  remarkable  can  be  discovered; 
at  the  sides  the  glands  become  longer;  the  first  ones  that  are 
intact  usually  curve  themselves  over  the  defect  and  partly 


478  EROSIONS— PERIGASTRITIS 

cover  it.     Recoven^  seems  to  take  place  by   the  simple 
aftergrowth  of  the  gland  remnants." 

Among  others  who  have  studied  the  condition  are  Mrchow, 
Langerhans,  Hartung,  Ewald,  Pariser,  Quintard,  and  ]\Ientz. 
Riegel  maintains  that  the  condition  is  not  a  distinct  patho- 
logic process;  he  believes  the  small  fragments  of  mucous 
membrane  washed  out  of  the  stomach  are  of  traumatic 
origin,  due  to  tearing  from  the  lavage  process. 

Etiology. — The  exact  etiology  of  erosions  of  the  stomach  is 
obscure.  Einhorn  reports  association  of  the  condition  wdth 
hj'perchlorhydria.  but  the  vast  majority  of  cases  have  been 
ascribed  to  chronic  gastritis.  The  same  factors  which  pre- 
dispose to  gastritis  are  sometimes  associated  with  erosions 
of  the  stomach,  but  in  most  cases  of  gastritis  there  is  no 
evidence  of  erosions.  In  many  cases  in  which  gastritis  could 
be  excluded,  Turck  found  erosions  of  the  mucous  membrane. 
He  claims  also  to  have  found  them,  in  the  same  cases,  in 
other  locations,  mouth,  pharynx,  colon;  and  many  a  so-called 
ulcer  of  the  rectum  presents  more  of  the  sjniptoms  of  erosion 
than  of  ulcer.  In  lavage  of  the  colon,  particles  are  found 
in  the  wash-water  smiilar  to  the  specimens  of  mucous 
membrane  found  in  the  wash-water  from  the  stomach  of 
the  same  patients. 

Numerous  factors  predispose  to  erosion  of  the  stomach. 
Children  who  have  been  ill-fed  and  those  who  do  not  appro- 
priate the  full  nutrition  of  their  food,  the  vascular  walls 
losing  ''tone"  though  the  body  weight  may  not  suffer,  are 
more  or  less  subject  to  erosion  of  the  stomach.  The  abuse 
of  alcohol  is  also  a  factor.  Pariser  asserts  that  chlorosis 
maj'  play  an  important  part  in  the  causation  of  erosions. 
It  would  appear  that  erosions  result  from  obstruction  of 
the  circulation  to  the  stomach,  combined  with  irritation 
of  the  gastric  mucosa. 

Symptoms. — Pain  is  the  most  pronounced  symptom.  This 
comes  on  after  partaking  of  food,  irrespective  of  the  kind. 
The  pain  of  erosions  differs  from  that  of  gastric  ulcer, 
inasmuch  as  it  is  not  intense,  never  boring  or  cramp-Uke, 
though  Pari.ser  states  that  in  the  cases  under  his  observation 


EROSIONS  OF  THE  STOMACH  479 

the  pains  were  described  as  "unbearable  suffering."  It  is 
probable  that  the  annoying  constancy  of  this  symptom 
impresses  the  patient  with  a  sense  of  great  severity.  Pain 
comes  on  immediately  after  eating,  persists  for  an  hour  or 
two,  then  gradually  subsides.  In  some  cases  it  persists  all 
the  time,  irrespective  of  the  partaking  of  food.  Lavage 
generally  dispels  the  pain.  Frequently  patients  have  no 
appetite.  In  some  cases  vomiting  is  one  of  the  distressing 
symptoms.  Pariser  advises  control  investigation  of  the 
fasting  stomach  in  order  to  differentiate  erosions  from  gastric 
ulcer  or  from  a  neurosis. 

Patients  lose  weight  at  the  beginning  of  their  sickness,  but 
after  that  the  weight  is  fairly  constant.  They  present  a 
picture  of  emaciation,  protruding  jaws,  and  hollow  cheeks, 
but  not  the  cachexia  which  characterizes  carcinoma  and  the 
severe  wasting  diseases.  Patients  with  gastric  erosions 
complain  of  weakness  and  inability  to  work,  a  feeling  most 
marked  directly  after  meals. 

Diagnosis. — The  most  important  diagnostic  feature  of 
gastric  erosions  is  the  presence  in  the  water,  after  lavage, 
of  small  pieces  of  gastric  mucous  membrane.  Einhorn 
describes  them  as  0.3  to  0.4  Cm.  long,  about  the  same  width, 
and  of  a  blood-red  color.  Under  the  microscope,  well 
preserved  glands  and  accumulations  of  red  blood  corpuscles 
may  be  seen.  Blood  is  almost  never  found  in  the  washings 
which  contain  membranous  exfoliations.  This  is  explained 
by  the  probability  that  the  pieces  of  gastric  mucosa  peel 
off  some  little  time  before  the  performance  of  lavage. 
When  the  return  water  is  tinged  with  blood,  this  is  the  result 
of  coughing  which  violently  contracts  the  stomach.  It  is 
difficult  to  ascertain  whether  the  exfoliations  are  from  the 
same  spots  day  by  day,   or  from  different  locations. 

Pathology. — The  pathology  of  erosions,  according  to  Ewald 
(who  has  studied  it  soon  after  the  death  of  the  patient), 
presents  the  following  picture:  "The  ducts  of  the  glands 
were  packed  full  of  red  blood  cells,  having  their  origin  from 
hemorrhages  on  the  surface  of  the  mucous  membrane,  which 
in  turn  could  only  have  come  from  the  capillary  network 


480  EROSIONS— PERIGASTRITIS 

situated  close  to  the  free  surface  of  the  mucous  membrane. 
They  develop  into  little  hemorrhagic  erosions,  small  streak- 
like or  rounded  losses  of  substance,  from  the  size  of  a  millet 
seed  to  that  of  a  pea,  on  which  at  times  a  blackish-brown 
extravasation  of  blood  is  found,  together  with  a  simultaneous 
loosening  of  the  mucous  membrane."  In  the  majority  of 
cases  there  is  a  decrease  in  the  hydrochloric  acid  secretion. 
In  some  there  is  more  or  less  profuse  secretion  of  mucus. 

Prognosis. — The  course  of  the  disease  is  usually  prolonged, 
extending  sometimes  over  several  years.  There  are,  how- 
ever, intervals  of  improvement. 

Treatment. — The  dietetic  treatment  depends  upon  the 
results  of  analysis  of  the  gastric  contents.  The  condition  of 
the  secretion  determines  whether  the  case  shall  be  treated 
as  subacid  gastritis,  acid  gastritis,  or  hyperchlorhydria. 
The  alkalies  are  indicated  in  hyperacidity;  the  vegetable 
bitters  in  cases  characterized  by  a  deficiency  of  hydrochloric 
acid  secretion. 

There  is,  as  a  rule,  marked  muscle  weakness;  consequently 
food  is  apt  to  remain  longer  in  the  stomach  than  is  normal. 
Time  must  be  given  for  one  meal  to  pass  through  the  pylorus 
into  the  intestine  before  a  second  meal  is  taken.  Turck 
advocates  two  meals  a  day,  one  in  the  morning  and  one  at 
night.  There  msiy  be,  he  says,  some  distress  in  the  beginning 
from  the  loss  of  the  noonday  meal,  but  this  is  purely  a 
question  of  habit,  and  the  patient  soon  becomes  accustomed 
to  taking  two  meals  daily,  feeling  more  comfortable.  With 
great  loss  of  motor  power  dietetic  measures  must  be  ob- 
served. Chopped  meat  and  wheat  bread  are  all  that  is 
desirable  in  the  beginning.  We  may  gradually  add  to  this, 
chicken,  fish  (boiled  or  baked,  not  fried),  sweetbread,  and 
calf's  brain.  Vegetables  may  be  added  later — potatoes, 
squash,  and  mashed  turnips. 

General  Treatment. — The  indication  for  general  treat- 
ment is  the  equalization  of  the  circulation,  for  which  Turck 
advises  the  bath  and  extension  movements.  The  patient 
is  placed  in  the  bath  at  105°  F.,  and  the  temperature  is 
rapidly  increased  to  110°  or  115°  F.     ^^'hen  his  skin  has 


EROSIONS  OF   THE  STOMACH  481 

become  reddened,  he  is  taken  from  the  bath  and  rubbed 
with  ice.  The  ice  further  stimulates  circulation  and  reduces 
the  temperature  caused  by  the  heat  of  the  bath. 

Local  Treatment. — The  local  treatment  of  the  stomach 
in  gastric  erosions  is  of  great  importance. 

1.  Nitrate  of  Silver. — Beneficial  results  have  been  obtained 
by  spraying  the  stomach  with  a  solution  of  nitrate  of  silver 
(1  or  2  parts  to  1000).  Einhorn  administers  this  treatment 
as  follows:  First  the  stomach,  in  a  fasting  condition,  is 
washed  out  with  lukewarm  water,  and,  all  the  water  being  re- 
moved, the  tube  is  withdrawn.  The  spray  apparatus  is  filled 
with  10  Cc.  (oiiss)  of  a  0.1  to  0.2  per  cent,  solution  of  nitrate 
of  silver,  and  the  tube  end  dipped  in  lukewarm  water  and 
introduced  into  the  stomach;  then  the  whole  or  the  greater 
part  of  the  solution  in  the  bottle  is  sprayed.  The  bottle  is 
then  opened  and  the  spray  tube  removed  from  the  stomach. 
Einhorn  alternates  the  nitrate-of-silver  spray  treatment 
with  intragastric  galvanization. 

The  following  prescription  has  been  found  useful : 

Gm.  or  Cc. 

I^ — Argenti  nitratis 0.25  gr.  iv 

Aquae  destillatse        .      .      .      .       q.  s.  ad      240 . 0         §  viij 
Misce. 
Sig. — Tablespoonful  three  times  a  day,  before  each  meal. 

2.  The  Bismuth  Treatment. — This  consists  of  lavage  every 
other  day  with  an  alkaline  suspension  of  bismuth,  to  dis- 
solve mucus,  and  the  administration  of  bismuth  subnitrate 
in  doses  of  1  to  2  Gm.  (15  to  30  grains)  three  times  a  day 
(before  meals). 

Gm.  or  Cc. 

IJ — Bismuthi  subnitratis 30.0  5j 

Aquae  chloroform!  .      .       q.  s.  ad      240.0  5 viij 

Misce. 
Sig. — Tablespoonful  three  times  daily,  before  each  meal. 

3.  Suprarenal  Gland. — Einhorn  also  recommends  an 
extract  of  the  suprarenal  gland.  He  administers  it  every 
other  day  in  powder  form — about  3  grains.  When  this  is 
used  the  nitrate-of-silver  spray  is  omitted. 

31 


482  EROSIONS— PERIGASTRITIS 

Stockton  and  Jones  recommend  attention  to  the  general 
health,  and  advise  strychnine,  arsenic,  malt  and  cod-liver 
oil,  fresh  air,  sunlight,  mountain  climbing,  and  other 
invigorating  exercise,  to  be  used  appropriately. 


PERIGASTRITIS 

According  to  Mikulicz,  perigastritis  may  develop  in  the 
course  of  an  ulcer  of  the  stomach,  in  two  forms,  namely, 
as  a  loose  adhesion  between  the  stomach  and  neighboring 
organs,  whereby  the  former  is  subjected  to  traction;  and, 
secondly,  as  tumor-like  infiltrations  caused  by  the  gradual 
advance  of  the  ulcer  toward  the  abdominal  wall. 

The  local  inflammation  runs  a  latent  course,  and  the 
symptoms  are  obscured  by  the  more  pronounced  pains  of 
the  gastric  ulcer.  Perigastric  adhesions  are  caused  by  ulcera- 
tion of  the  stomach  and  duodenum,  gallstones  in  the  gall- 
bladder or  bile  ducts,  traumatism,  malignant  disease,  pan- 
creatic disease,  umbilical  hernia,  and  possibly  tubercle  and 
syphilis.  The  adhesions  are  usually  to  the  pancreas,  liver, 
or  spleen.  Adhesions  to  the  anterior  abdominal  wall  are 
very  rare.  Symptoms  due  to  adhesions  arise  usually  in 
cases  where  the  attachment  is  to  one  of  the  more  mobile 
organs,  which  drag  on  the  adhesions.  Liver  or  pancreas 
adhesions  are  usually  short  and  broad;  those  to  the  colon 
or  gall-bladder  may  be  long  and  cord-like.  The  shape  of 
the  stomach  may  be  markedly  or  only  slightly  altered.  The 
pylorus  may  be  narrowed,  or  the  stomach  may  be  nearly 
divided  into  two  parts — hour-glass  stomach.  Other  effects 
are:  Dilatation  by  traction,  and  interference  with  motility 
and  contracting  power.  The  history  of  the  case  is  usually 
a  long  one,  and  the  symptoms  finally  complained  of  are  not 
infrecjuently  preceded  by  others  more  characteristic  of 
gastric  ulcer  or  gallstone  colic.  Pain  is  the  most  common 
and  characteristic  symptom,  and  a  marked  feature  is  the 
fact  that  it  is  frequently  confined  to  one  locality.  It  is 
usually  greatly  influenced  by  the  position  of  the  patient, 


PERIGASTRITIS  483 

but  very  little  by  food.  Violent  exertion  often  brings  on 
the  pain;  it  is  sometimes  relieved  by  firm  pressure  or  band- 
aging. Local  tenderness  is  usually  present.  The  secretion 
of  gastric  juice  is  normal. 

Forms. — ^Among  the  varieties  of  this  pathologic  condition 
are: 

1.  Local  adhesive  growths,  ivhich  may  or  may  not  give 
rise  to  distressing  symptoms.  These  adhesions  may  cause 
pain  of  greater  or  less  severity,  especially  when  the  adhesive 
bands  are  subjected  to  traction  by  various  bodily  movements 
(walking,  gymnastics)  or  the  distention  of  the  stomach  with 
food.  The  adhesions  may  result  in  disturbing  the  motility 
of  the  stomach.  The  diagnosis  is  often  difficult,  since  little 
or  nothing  can  be  elicited  by  palpation.  According  to  Rosen- 
heim, a  diagnosis  of  perigastritis  is  warranted  when,  after 
the  healing  of  a  gastric  ulcer,  the  painful  symptoms  persist, 
or  when  the  usual  treatment  of  the  stomach  for  disturbances 
of  motiUty  does  not  lead  to  improvement.  Boas  maintains 
that  perigastric  adhesions,  as  such,  are  only  exceptionally 
recognizable ;  in  most  cases  one  can  hardly  arrive  at  a  posi- 
tion beyond  probability  or  supposition.  The  chief  point 
lies,  not  in  recognizing  the  perigastritis  or  the  character 
of  the  tumor,  but  in  diagnosticating  the  latent  gastric  ulcer 
which  leads  to  these  complications.  Duplant  says  that 
symptoms  of  perigastritis  are  commonly  seen  in  dyspeptics 
in  whom  an  ulcer  has  been  suspected  for  a  long  time.  Ac- 
cording to  this  author,  the  only  symptom  of  value  is  palpa- 
tion of  an  indurated  mass  corresponding  to  the  affected  part. 

2.  Perigastritis  with  the  formation  of  tumors.  When  the 
symptoms  of  gastric  ulcer  persist  for  months  or  years,  a 
tumor  becomes  apparent  in  the  left  epigastric  region.  The 
growth  of  the  tumor  is  gradual,  and  the  mass  is  often 
adherent  to  the  anterior  abdominal  wall.  Vomiting  is 
frequently  a  symptom.  It  may  not  be  possible  to  exclude 
the  alternative  of  malignancy  until  after  a  somewhat 
extended  period  of  observation. 

In  1895  Hofmeister  reported  a  case  of  gastric  ulcer 
adherent  to  the  anterior  abdominal  parietes  which,  causing 


484  EROSIONS— PERIGASTRITIS 

perigastritis  and  infiltration  of  the  anterior  abdominal  wall, 
gave  rise  to  a  tumor.  Hofmeister  considers  the  following 
symptom-complex  as  typical  of  these  cases:  Some  time  after 
the  beginning  of  long-continued  indigestion  of  greater  or 
less  severity,  a  tumor,  very  gradually  increasing  in  size, 
develops  in  the  left  epigastrium.  During  the  later  years 
of  the  malady  pain  becomes  pronounced ;  this  is  verj"  severe, 
and  is  confined  to  the  vicinity  of  the  tumor;  it  takes  the 
form  of  attacks,  especially  after  the  ingestion  of  food. 
Vomiting  is  sometimes  observed;  hematemesis  occasionally. 
Finally  the  nutrition  is  impaired  to  a  marked  degree,  and 
the  patient  may  become  greatly  emaciated. 

Diagnosis. — ^^Tiite^  does  not  favor  the  exploratory  lapar- 
otomy which  Boas  states  is  an  acknowledged  and  necessary 
measure  for  the  recognition  and  cure  of  perigastritis.  He 
urges  a  more  careful  study  of  the  sj^mptoms  in  order  that 
a  diagnosis  may  be  made  and  proper  treatment  instituted 
at  an  early  period.  He  believes  that  with  some  care  and 
study  the  diagnosis  of  perigastric  adhesions  can  be  made  in 
most  instances  without  operation.  Adhesions  from  gastric 
ulcer  are  by  no  means  uncommon;  in  the  postmortem  room 
about  45  per  cent,  of  the  cases  of  gastric  ulcer  show  more 
or  less  adhesion  to  neighboring  organs.  Fenwick's  table 
of  123  cases  shows  the  pancreas  and  liver  to  be  the  organs 
most  frequently  involved  in  the  adhesions.  Adhesion  to 
the  pancreas  frequently  saves  the  patient  from  the  danger 
of  perforation.  White  bases  his  remarks  on  a  study  of  a 
series  of  five  cases  which  submitted  to  operation.  In  all 
of  these  cases  severe  pain  was  the  prominent  symptom, 
two  of  the  patients  requiring  large  amounts  of  morphine. 
Pain  is  usually  located  at  the  upper  part  of  the  abdomen, 
and  a  history  of  its  continuance  for  years  is  of  the  utmost 
diagnostic  value.  The  pain  is  apt  to  be  of  a  paroxj^smal 
character,  but  some  j^ain  is  nearly  always  present.  Carci- 
noma is  the  only  other  condition  which  is  apt  to  produce 
prolonged  and  constant  jiain  wilh  acute  exacerbations. 
In  cases  of  perigastric  adhesions  little  or  no  loss  of  flesh 

'  Lf)i)(I()n  Laticct.  Novonihor  30,  IHOl. 


PERIGASTRITIS  485 

is  observed,  the  eoiidition  is  seldom  fatal,  and  the  patients 
are  mostly  young  people.  In  none  of  his  cases  did  White 
find  that  the  taking  of  food  produced  an  increase  of  pain. 
The  paroxysmal  character  of  the  pain  is  supposed  to  be 
due  to  peristalsis,  which  causes  a  dragging  upon  the  adhe- 
sions. It  is  thought  that  many  cases  of  "gastralgia," 
''hysteria,"  or  ''hypochondriasis,"  if  carefully  investigated, 
would  be  found  to  be  due  to  intra-abdominal  adhesions. 
Local  tenderness  is  sometimes  elicited,  and  more  rarely 
still  the  matting  together  of  the  organs  can  be  made  out 
by  palpation.  Dilatation  of  the  stomach  is  often  present, 
but,  unlike  that  due  to  ulcer,  there  will  be  no  vomiting,  the 
tongue  will  be  clean,  and  there  will  be  few  symptoms  of 
indigestion.  Severe  pain,  in  fact,  is  the  most  prominent 
symptom.  It  must  be  remembered,  of  course,  that  peri- 
gastric adhesions  and  an  unhealed  gastric  ulcer  may  be 
associated.  When  the  symptoms  are  due  entirely  to  the 
adhesions,  the  pain  is  apt  to  be  constant  and  of  long  dura- 
tion, more  pronounced  when  the  stomach  is  empty  than 
when  it  is  full ;  it  is  not  produced  or  increased  by  the  taking 
of  food.  The  situation  of  the  adhesions  will  also  influence 
the  symptoms.  For  instance,  if  a  band  passes  from  the 
stomach  to  the  colon,  the  contraction  of  either  of  these 
organs  will  cause  severe  pain;  but  if  a  large  area  of  the 
stomach  is  fixed  to  the  pancreas,  it  is  not  likely  that  the 
pain  will  be  severe.  The  history  of  an  old  gastric  ulcer  is 
of  the  greatest  value. 

Treatment. — Prophylaxis. — This  consists  in  the  early  diag- 
nosis of  gastric  ulcer  and  its  early  cure,  for  the  sooner  an 
ulcer  heals  the  less  opportunity  is  there  for  the  formation 
of  adhesions.  Of  therapeutic  agents,  only  fibrolysin  and 
thiosinamine  are  worthy  of  consideration.  These  drugs  may 
be  used  in  the  less  severe  forms  of  adhesions,  cicatricial 
stenosis,  and  the  so-called  "hour-glass  contraction."  The 
treatment  of  cicatricial  stenosis  by  fibrolysin  has  been 
described  (p.  414).  Tabora  has  recommended  thiosinamine, 
together  with  massage  of  the  distended  stomach,  as  follows : 
For  three  months,  daily,  1  Cc.  (15  minims)  of  a  20-per-cent. 


486  EROSIONS— PERIGASTRITIS 

thiosinamine-glycerin-water  solution  hypoderniically ;  effleur- 
age  at  the  same  time  over  the  stomach  distended  with  air. 
The  so-called  hour-glass  stomach  is  to  be  treated  in  other 
respects  as  motor  insufficiency  of  the  second  degree. 

When  a  diagnosis  of  perigastritis  has  been  made  with 
reasonable  certainty,  too  much  time  should  not  be  spent 
with  internal  medication,  inasmuch  as  surgical  intervention 
is  indicated.  In  sunple  adhesions  good  results  have  been 
obtained  bj^  simply  breaking  them  up.  TMien  the  condition 
is  comphcated  viith  motor  disturbance,  a  gastroenteros- 
tomy should  be  performed.  The  perigastric  tumor  must  be 
treated  surgically.  The  surgical  treatment  for  cicatricial 
stenosis  of  the  pylorus,  and  the  indications  therefor,  have 
been  discussed  in  another  chapter  (p.  209).  It  is  important 
for  the  surgeon  to  bear  in  mind  that  there  may  be  two 
ulcers  and  therefore  two  sets  of  adhesions  in  the  same  case. 
It  is  a  mistake,  in  cases  of  gastric  ulcer  with  sjmiptoms  of 
adhesions,  to  attempt  a  cure  by  rectal  feeding;  the  patient 
is  sure  to  lose  ground  under  such  treatment. 

Promotion  of  visceral  movement  is  the  most  efficient 
means  of  preventing  adhesion  of  raw  peritoneal  surfaces — 
movement  in  bed,  general  massage,  and  mild  laxatives. 
When  the  adhesions  cannot  be  separated  it  may  become 
necessary  to  perform  pyloroplasty  or  gastrojejunostomy. 


CHAPTER    XXII 

ARTERIOSCLEROSIS— SYPHILIS— TUBERCULOSIS 
ARTERIOSCLEROSIS 

Sclerosis  of  the  gastric  arteries  may  be  responsible  for 
any  one  of  the  three  following  pathologic  manifestations: 

1.  Gastric  Hemorrhages. — The  cause  of  the  hemorrhages  is 
mihary  aneurism  of  the  gastric  arterioles,  developing  on 
sclerotic  bases.  The  diagnosis  can  be  made  wdth  a  reason- 
able degree  of  probability  only  in  patients  of  advanced  age 
who  are  affected  with  a  general  arteriosclerosis.  The  treat- 
ment of  this  form  of  hemorrhage  is  the  same  as  that  of 
gastrorrhagia  from  other  causes. 

2.  Gastric  Ulcer. — This  condition  is  likely  to  supervene 
in  vascular  areas  in  which  the  blood  supply  has  become 
defective  in  consequence  of  sclerotic  obhteration  of  the 
arterioles.  The  treatment  is  that  of  the  round  or  peptic 
ulcer. 

3.  Abdominal  Angina. — Pain  of  a  severe  and  paroxysmal 
nature  sometimes  follows  sclerosis  of  the  abdominal  aorta 
and  its  branches.  The  attacks  are  apt  to  take  place  at 
night  after  bodily  exertion  or  mental  excitement. 

Arteriosclerosis  consists  of  a  thickening  of  the  intima  as 
a  result  of  primary  changes  in  the  media  and  adventitia. 
The  sclerotic  condition  may  be  diffuse  or  circumscribed; 
later  in  the  progress  of  the  disease  it  involves  the  media 
and  adventitia.  We  owe  our  conception  of  arteriosclerosis 
as  a  clinical  entity  to  the  studies  of  Gull  and  Sutton. 

Etiology. — Among  the  important  factors  producing  sclerotic 
changes  in  the  arteries  are: 

1.  Old  Age. — Arteriosclerosis  is  preeminently  a  disease 
of  the  later  years  of  life,  when  it  occurs  as  an  involution 


488       ARTERIOSCLEROSIS— SYPHILIS— TUBERCULOSIS 

process,  an  expression  of  the  natural  wear  and  tear  to  which 
the  arteries  are  subjected.  Longevity  is  largely  a  vascular 
question;  the  relationship  is  well  expressed  in  the  adage, 
"A  man  is  as  old  as  his  arteries." 

2.  Toxic  Factoids. — Alcohol,  lead  poisoning,  and  gout  are 
important  factors  in  the  causation  of  arteriosclerosis. 

3.  Syphilis. — Syphilis,  inherited  or  accjuired,  is  a  most 
important  cause  of  sclerotic  changes  in  the  arteries  of  the 
young  and  the  middle-aged. 

4.  Overeating.- — Overeating  is  an  important  etiologic 
factor.  Osier  quotes  George  Cheyne's  thirteenth  aphorism, 
which  contains  a  vast  amount  of  dietetic  sense:  ''Every 
wise  man  after  fifty  ought  to  begin  to  lessen  at  least  the 
quantity  of  his  aliment,  and  if  he  would  continue  free  of 
great  and  dangerous  distempers  and  preserve  his  senses  and 
faculties  clear  to  the  last  he  ought  every  seven  years  to 
go  on  abating  gradually  and  sensibly,  and  at  last  descend 
out  of  life  as  he  ascended  into  it,  even  into  the  child's 
diet." 

5.  Overwork. — Muscular  overwork  or  prolonged  and 
severe  exercise  tends  to  produce  hypertension  by  increasing 
the  peripheral  resistance. 

Pathology. — The  changes  to  be  described  under  this  head- 
ing are  of  a  degenerative  character,  and  have  an  important 
bearing  upon  the  integrity  of  the  arterial  walls  as  well  as 
upon  the  viscera  supplied  by  the  sclerosed  arteries. 

Owing  to  the  proliferation  of  endothelium  and  to  an 
increase  in  the  connective  tissue  of  the  intermediate  layer, 
a  thickening  of  the  intima  results,  which  may  wholly  or 
practically  occlude  the  lumina  of  small  arteries.  In  the 
large  arteries  the  new  tissue  may  form  beneath  the  endo- 
thelium diffusely  or  in  circumscribed  masses.  The  endo- 
thelium may  remain  intact  or  it  may  undergo  various 
changes;  it  may  proliferate,  or  it  may  become  fatty  or 
necrotic.  The  newly  formed  fibrous  tissue  of  the  intima  is 
apt  to  undergo  fatty  degeneration,  to  become  necrotic,  and 
to  disintegrate.  Cavities  of  varying  size,  containing  dis- 
integrated tissue,  fat  and  cholesterin  crystals,  develop  in 


ARTERIOSCLEROSIS  489 

the  newly  formed  tissue  into  what  have  been  designated 
atheromatous  cysts.  These  cysts  may  extend  toward  the 
lumen  of  the  vessels,  opening;  into  which  they  may  give 
rise  to  emboli  or  form  rough  ulcers  (often  with  undermined 
edges)  upon  which  thrombi  may  form.  In  the  newly  formed 
tissue  of  the  intima,  as  well  as  in  the  necrotic  foci  and  in  the 
detritus  of  the  cysts,  calcification  may  occur.  Fatty  degen- 
eration, atrophy,  and  calcification  may  occur  in  the  muscu- 
laris  and  adventitia  of  the  involved  vessels. 

Ortner,  to  whom  we  are  indebted  for  much  light  on  this 
obscure  condition,  described  a  case  of  general  arteriosclerosis 
involving  the  superior  and  inferior  mesenteric  arteries  and 
through  them  the  intestines.  The  s^nnptoms  had  to  do 
largely  with  the  intestines,  and  consisted  of  severe  pains 
in  the  region  of  the  navel,  coming  on  two  or  three  hours 
after  eating,  extreme  distentions  from  gas,  difficulty  in 
breathing,  and  explosive  belching.  The  ascending  and 
transverse  colon  were  distended  to  such  an  extent  as  to  be 
visible  through  the  abdominal  wall.  Ortner  explained  the 
condition  on  the  basis  of  a  pathologic  examination.  The 
aorta  was  thickened  and  calcified;  there  w^as  a  thick  deposit 
of  lime  salts  about  the  mouth  of  its  branches,  especially  the 
mesenteric  arteries,  and  the  small  branches  of  these  were 
stifT,  inelastic,  and  probably  contracted.  The  result  of  this 
was  that  the  intestines  did  not  receive  a  sufficient  quantity 
of  blood  from  the  aorta  through  the  mesenteric  arteries, 
and  what  did  come  to  them  was  poorly  distributed  because 
of  the  changes  in  the  arterioles.  The  intestinal  w^alls  were 
poorly  nourished;  the  muscular  coat,  weak  and  inefficient, 
was  unable  to  do  its  work,  and  when,  two  or  three  hours 
after  eating,  the  intestines  began  to  be  called  on  to  carry 
out  their  part  in  digestion,  they  could  not  do  so — their 
motility  was  impaired,  and  probably  also  the  secretory  and 
absorptive  functions.  The  arteries  supplying  the  stomach 
are  in  no  way  exempt  from  arteriosclerotic  degeneration. 
In  fact,  the  round  ulcer  has  been  seen  frequently  as  a 
result  of  the  trophic  disturbances  produced  by  arterio- 
sclerosis. 


490     Arteriosclerosis— s  yphilis— tuberculosis 

The  same  causes  to  which  Ortner  attributes  the  intestinal 
symptoms  would  account  for  similar  sjTiiptoms  referable  to 
the  stomach. 

Symptoms. — These  general  arteriosclerotic  changes  give 
rise  to  symptoms  which  are  attributed  by  the  patient  to 
the  stomach  and  some  primary  disorder  of  digestion.  The 
patient  can  never  be  fully  con\'inced  but  that  if  his  stomach 
were  in  good  condition  he  would  be  well  again.  Among  the 
subjective  symptoms  are  a  feeUng  of  fulness  in  the  epigas- 
trium, pain  under  the  ensiform  cartilage  running  down  the 
left  arm,  gaseous  eructations,  and  extreme  nervousness  and 
anxiety.  There  is.  as  a  rule,  immediate  relief  on  belching. 
These  are  the  leading  sj^mptoms  which  were  complained 
of  by  a  number  of  patients,  and  which  subsided  after  appro- 
priate treatment  directed  to  the  vascular  system.  The 
digestive  disturbances  are  secondary  to  primary  changes  in 
the  arterial  system.  In  fact,  not  only  the  stomach,  but  the 
whole  intestinal  tract  is  affected  by  the  changes. 

Diagnosis. — In  his  diagnosis  the  physician  should  not  be 
led  astray  by  the  complaints  of  his  patient  as  to  indigestion, 
pain  in  the  stomach,  distention,  and  belching,  but  should 
make  a  careful  search  for  the  underlying  cause  of  the  diges- 
tive disturbances. 

In  patients  past  middle  hfe  who  complain  of  pain  in  the 
stomach,  distention  after  eating  if  they  attempt  any  physi- 
cal exertion,  and  dyspnea,  relieved  by  belching  of  gas — 
especially  when  nocturnal  seizures,  accompanied  by  dis- 
tention, heart  disturbances,  dyspnea,  and  great  anxiety, 
are  prominent  symptoms — a  careful  examination  of  the 
vascular  system  will,  as  a  rule,  reveal  the  real  cause  of  the 
condition.  Such  examination  usually  shows  a  heart  some- 
what enlarged,  an  aortic  second  sound  sharp  and  snapping, 
a  murmur  over  the  aortic  area  and  rough  sounds  over  the 
aorta  itself,  pulsation  in  the  episternal  notch,  attacks  of 
pain  over  the  precordial  region  radiating  to  the  arm,  marked 
tenderness  over  the  abdominal  aorta  down  to  the  navel, 
urine  perhaps  increased  in  amount  or  containing  allnimin 
in  small  quantit}',  or  both  increased  and  albuminous.     All 


ARTERIOSCLEROSIS  491 

these  point  unmistakably  to  the  circulatory  system  as  the 
real  cause  of  the  trouble. 

Treatment. — The  diet  should  be  plain,  nutritious,  and 
easily  digestible.  The  evening  meal  should  be  limited  in 
size,  to  minhnize  the  formation  of  gas.  Alcohol,  tobacco, 
tea  and  coflfee  should  be  interdicted  in  arteriosclerosis,  or 
restricted  to  a  minimum.  Moderation  in  eating  and  drink- 
ing is  essential  to  the  arrest  of  the  pathologic  process  going 
on  in  the  arteries.  Animal  foods  should  be  restricted,  for 
the  digestion  of  these  foods  develops  substances  that  add 
to  the  abnormal  conditions  already  prevailing  in  the  body. 

Bathing,  fresh  air,  moderate  exercise,  and  attention  to 
the  bowels  should  enter  into  the  hygienic  treatment.  In- 
tense excitement  should  be  avoided.  Many  patients  require 
absolute  physical  and  mental  rest,  especially  as  they  enter 
the  stage  of  myocardial  incapacity.  By  proper  clothing  the 
peripheral  cumulation  should  be  protected  from  sudden 
changes  of  temperature. 

Of  medicinal  agents  for  the  treatment  of  arteriosclerosis 
producing  gastric  symptoms,  Akin^  reconmiends  diuretin, 
or  sodiosalicjdate  of  thiobromine,  in  doses  of  0.5  to  1  Gm. 
(8  to  15  grains)  three  times  a  day.  According  to  this 
writer,  so  satisfactory  is  diuretin  in  bringing  about  an 
ameUoration  of  sjTiiptoms  that  it  has  been  used  as  an  aid 
to  diagnosis  in  doubtful  cases.  Its  effects  depend  on  its 
powerful  action  in  overcoming  the  vascular  spasm  and  dilat- 
ing the  arterioles  so  that  they  allow  a  greater  flow  of  blocd 
to  the  sclerosed  areas.  It  has  been  suggested  by  Buch  that 
diuretin  may  neutralize  the  effect  of  some  toxic  agent  which 
tends  to  irritate  the  vasomotor  centres  and  cause  contraction. 
Whatever  the  exact  mode  of  action,  its  effects  are  very 
satisfactory,  and  its  use  may  be  continued  for  one  or  two 
weeks  or  even  longer  without  harm.  The  effect  may  then  be 
maintained  b}'  the  use  of  tincture  of  strophanthus,  5  to  8 
drops  three  times  a  day.  Strophanthus  has  been  observed 
to  act  so  much  like  diuretin  that  it  is  used  in  place  of  the 
latter  in  some  cases  in  which  expense  is  a  great  considera- 

^  Journal  of  the  American  Medical  Association,  June  5,  1909. 


492       ARTERIOSCLEROSIS— S  YPHILIS—TUBERC  U  LOS  IS 

tion.  Erythrol  tetranitrate,  introduced  as  a  useful  agent 
in  arteriosclerosis  by  Turney,  of  Flintshire,  England,  lowers 
blood  pressure  and  maintains  its  vasodilator  effect  for  a 
longer  period  of  time  than  other  preparations  of  the  same 
class.  Its  influence  upon  the  bloodvessels  is  manifest  in 
fifteen  to  twenty  minutes  after  the  dose  is  administered  and 
persists  for  three  to  four  hours.  The  dose  is  0.02  to  0.06 
Gm.  (I  to  1  grain).  Variation  in  the  amount  and  frequency 
of  the  dose  is  regulated  by  the  demands  of  the  case  and  the 
effect  on  the  patient. 

Brown, ^  in  recommending  the  iodides  in  arteriosclerosis, 
maintains  that  the  continued  good  effects  of  this  medication 
are  to  be  obtained  only  by  gradually  increasing  the  dosage 
until  the  sluggish  live  cells  are  sufficiently  stimulated  and 
enough  degenerated  cells  destroyed  to  insure  the  restitution 
of  function  in  the  tissues.  The  prolonged  administration 
of  small  doses  fails  to  accomplish  permanently  favorable 
results;  but  large  and  progressively  increasing  doses  produce 
strikingly  good  results,  in  early  cases  particularly.  He  advises 
that  in  the  use  of  potassium  iodide  the  patient  be  started 
with  a  0.6  Gm.  (10  grain)  dose  three  times  daily,  which 
should  be  daily  increased  until  4  to  4.6  Gm.  (60  to  70  grains) 
are  given  each  day.  lodism  can  be  prevented  by  the  careful 
exclusion  of  acids  from  the  diet,  and  by  neutralization  of 
the  acid  contents  of  the  stomach  by  means  of  any  agreeable 
alkali  (as  the  alkaline  mineral  waters).  With  potassium 
iodide  it  is  wise  to  combine  potassium  bicarbonate  in  the 
proportion  of  one  of  the  former  to  two  of  the  latter.  The 
combination  of  sodium  iodide  and  potassium  iodide  in  con- 
nection with  the  use  of  the  alkaline  waters  above  mentioned 
proves  more  satisfactory  than  the  separate  use  of  either; 
and  therefore,  when  the  use  of  the  iodides  is  to  be  continued 
for  a  long  period  of  time,  the  combination  should  be  pre- 
scribed. In  this  connection  it  should  be  stated  that  Romberg 
believes  potassium  iodide  reduces  the  viscosity  of  the  blood 
and  in  that  way  assists  in  the  relief  of  blood  pressure  and  in 
invigoration  of  the  arterial  tissues. 

'  .Journal  of  the  Aincricim  Modical  Assofliafioii,  January,  1910. 


ARTERIOSCLEROSIS  493 

Thyroid  extract  has  been  administered  in  arteriosclerosis, 
with  favorable  results,  due  to  its  power  to  control  high 
arterial  pressure. 

Aufrecht,'  in  a  treatise,  expresses  his  l)elief  that  the  ana- 
tomic process  of  arteriosclerosis  has  its  origin  in  the  vasa 
vasorum,  which  are  overloaded  with  red  blood  corpuscles; 
the  walls  of  the  vessels  of  the  connective  tissue  are  altered, 
and  the  result  is  an  obliteration  of  the  vasa  vasorum.  The 
media  and  intima  next  undergo  changes,  arteriosclerosis 
being  the  final  outcome.  As  to  treatment,  he  has  experi- 
mented with  potassium  iodide,  which  some  regard  as  a 
specific,  but  favors  iron,  which  he  has  employed  for  ten 
years.  He  claims  to  get  good  results  from  an  iron  pill  of 
the  following  composition: 

Gm.  or  Cc. 

I^ — Ferri  reducti .3.0  gr.  xlv 

Sodii  carbonatis  exsiccati 4.0  oj 

Pulveris  glj'cyrrhizse 2.0  5ss 

Extract!  glycyrrhizse,  q.  s. 

Misce  et  ft.  pil.  no.  Ix. 

Sig. — Two  pills  to  be  taken  three  times  a  day. 

The  use  of  these  pills  is  continued  for  two  months,  fol- 
lowed by  a  rest  of  a  fortnight  or  a  month,  when  the  treat- 
ment is  renewed.  Some  patients  have  been  kept  on  the 
treatment  for  four  years. 

In  the  endeavor  to  combat  arteriosclerosis  by  promoting 
vascular  metabolism,  strengthening  the  vasomotor  nerves, 
and  reducing  the  tension  of  the  vessels,  Trunecek  resorted 
to  the  hypodermic  administration  of  the  inorganic  blood 
salts.  His  results  have  been  confirmed  by  Tessier,  Levj', 
Merklen,  Zanoni,  and  others;  the  serum  acts  on  the  lime 
phosphate,  removes  dyspnea  by  increasing  the  alkalinity 
of  the  blood,  has  a  direct  effect  on  the  heart  and  the  vascular 
endothelium,  and  stimulates  the  vasomotor  system.  Levy 
has  found  that,  given  by  mouth,  the  salts  have  the  same 
effect   as  when  administered  hypodermically.     Under  the 

1  Zur  Pathologie  und  Therapie  der  Arteriosklerose. 


494       ARTERIOSCLEROSIS— SYPHILIS— TUBERCULOSIS 

trade  name  antisclerosin,  a  combination  consisting  of  these 
blood  salts  is  available.     Each  dose  (two  tablets)  contains: 


Gm.  or  Cc. 

I^ — Sodii  chloridi 

0.8 

gr.  xij 

Sodii  sulphatis 

0.08 

gr-ij 

Mag^esii  phosphatis, 

Sodii  carbonatis  exsiccati    . 

.   aa 

0.03 

gr.  ss 

Sodii  phosphatis, 

Calcii  glycerophosphatis 

.   aa 

0.025 

gr.  f 

This  represents  at  least  15  Cc.  of  Trunecek's  serum,  and 
equals  the  salt  contents  of  about  150  Cc.  of  blood  serum. 

Though  certain  cases  are  incurable,  antisclerosin  is  said 
to  relieve  the  subjective  and  objective  symptoms  even  in 
severe  cases.    Its  chief  field  of  usefulness  is  as  a  prophylactic. 


SYPHILIS 

Syphilis  of  the  stomach  is  a  very  rare  affection.  All  the 
cases  so  far  observed  have  occurred  during  the  tertiary 
stage  of  the  disease.  Gastric  syphilis  appears  in  three 
forms — (1)  specific  ulcers  of  the  stomach;  (2)  specific  tumors; 
(3)  specific  stenosis  of  the  pylorus.  The  syphilitic  ulcer  is 
the  most  frequent  manifestation  of  syphilis  affecting  the 
stomach;  it  may  develop  as  a  result  of  disturbances  in  the 
circulation  affecting  circumscribed  areas  of  the  gastric 
mucous  membrane,  and  having  as  its  primary  cause  a  spe- 
cific endarteritis.  Ulcers  may  also  arise  from  the  disinte- 
gration of  gummata  in  the  submucous  coat  of  the  stomach. 
The  gummatous  ulcer  develops  in  the  submucosa,  while 
that  caused  by  specific  endarteritis  is  essentially  an  ulcer 
of  the  mucosa;  neither  differs  in  any  way  from  the  ordinary 
round  ulcer,  except  that  the  specific  ulcer  is  much  less 
amenable  to  treatment. 

Diagnosis. — It  is  a  very  difficult  matter  to  make  a  diag- 
nosis of  syphilitic  ulcer,  and  the  clinician  nuist  rel}'  upon  the 
known  presence  of  syphilitic  infection  in  order  to  be  at  all 
certain  that  the  gastric  ulcer  is  of  luetic  origin.    The  pres- 


SYPHILIS  495 

ence  or  absence  of  the  Treponema  pallidum  (Spirochaete 
pallida),  according  to  both  Koch  and  Schmorl,  is  not  to  be 
depended  upon  in  determining  the  presence  or  absence  of 
ulcer  of  syphilitic  origin.  These  microorganisms  are  often 
absent  in  cases  of  undoubted  syphilis;  on  the  other  hand, 
Koch,  using  the  Levaditi  stain,  found,  in  cases  of  undoubted 
carcinoma  of  the  lung,  organisms  of  the  typical  appearance 
of  the  Treponema  pallidum.  Another  important  factor 
which  plays  a  part  in  the  anatomic  diagnosis  of  syphilis 
of  the  stomach  is  a  peculiar  vascular  change  of  high  grade, 
resulting  in  partial  occlusion  or  obliteration  of  vessels. 
Cellular  accumulations  are  found  about  the  vessels,  which 
become  thickened  from  cell  increase  thus  beginning  from 
without;  or  subendothelial  change  may  be  the  prominent 
feature.  The  process  tends  to  spare  many  vessels  entirely, 
while  others  are  thickened  to  the  point  of  occlusion.  Syphi- 
litic ulceration  of  the  stomach  should  be  distinguished 
clinically  from  carcinoma  and  the  gastric  crises  of  locomotor 
ataxia.  The  differentiation  between  syphilitic  ulcer  and 
other  conditions  producing  dyspeptic  symptoms  may  be 
further  made  by  a  course  of  antisyphilitic  remedies,  such  as 
potassium  iodide,  which  will  usually  ameliorate  syphilitic 
symptoms  while  the  same  treatment  would  have  the  reverse 
effect  upon  ordinary  cases  of  gastritis. 

According  to  Peter,  a  greater  number  of  men  than  women 
are  affected  by  syphilis  of  the  stomach.  The  time  between 
the  chancre  and  the  lesion  varies  from  two  to  forty  years. 

Allen  A.  Jones  has  called  attention  to  syphilis  as  an 
important  cause  of  gastralgia.  He  maintains  that  there  are 
cases  with  symptoms  referable  to  the  stomach  that  are  not 
caused  by  any  apparent  lesion  of  that  organ,  but  are  rather 
the  result  of  nervous  disturbance,  and  disappear  under 
antisyphilitic  treatment. 

Treatment. — The  treatment  of  syphilis  of  the  stomach 
consists  in  the  methods  and  agents  employed  in  cases  of 
gastric  ulcer  and  gastric  hemorrhage,  together  with  such 
specific  remedies  as  mercury  and  the  iodides,  the  latter 
being  tolerated  well  by  the  luetic  stomach. 


496       ARTERIOSCLEROSIS— S  YPHILIS—T  UBERC  ULOSIS 

Syphilitic  stenosis  of  the  pylorus  is  an  exceedingly  rare 
condition,  which  may  be  due  to  cicatrices  of  syphilitic  ulcers 
or  tumors  and  gummatous  infiltration  in  the  region  of  the 
pylorus.  The  treatment  for  this  condition  is  the  same  as 
for  motor  disturbances. 

Williams^  classifies  the  hypodermic  treatment  of  syphilis 
under  three  heads — subcutaneous,  intramuscular,  and  intra- 
venous. The  advantages  of  hypodermic  medication  are: 
accuracy  and  regulation  of  dose  of  the  mercury  adminis- 
tered, rapidity  of  action,  certainty  of  absorption,  non- 
impairment  of  the  digestive  functions,  and  mitigation  of 
intestinal  disturbances.  Of  the  methods  of  hypodermic 
medication,  the  intramuscular  is  perhaps  superior  to  either 
of  the  other  two.  The  most  convenient  location  for  the 
administration  of  mercury  is  the  gluteal  region,  the  right 
and  left  side  being  used  alternately.  The  best  location  for 
the  puncture  is  above  the  level  of  the  great  trochanter, 
supposed  to  be  the  region  of  least  sensation.  The  skin 
should  be  properly  cleansed,  and  the  needle  should  be 
thoroughly  sterilized  before  its  introduction  by  being  held  for 
a  few  seconds  in  the  flame  of  a  spirit  lamp.  After  cooling, 
the  needle  may  be  plunged  into  the  muscle  tissues  at  right 
angles  until  the  proper  depth  is  reached,  which  will  vary 
with  the  amount  of  subcutaneous  fat,  but  is  usually  from 
three-quarters  of  an  inch  to  one  inch  below  the  surface  of 
the  skin.  After  the  needle  is  withdrawn  the  site  of  the  injec- 
tion should  be  gently  pressed  by  the  finger  for  a  few  moments. 
The  puncture  wound  should  be  sealed  by  means  of  aseptic 
absorbent  cotton  saturated  in  collodion. 

Meltzer  and  Auer^  have  demonstrated  that  absorption 
after  an  intramuscular  injection  is  far  more  rapid  than 
after  a  subcutaneous  one.  The  sacrospinal  muscle  presents 
a  large,  roundish,  compact  mass  of  muscle  tissue,  consisting 
of  fine  muscle  bundles,  densely  packed,  with  very  little 
connective  tissue  between.  On  the  other  hand,  the  gluteal 
muscles  are  made  up  of  flat  nuisclc  layers  consisting  of 

'  London  Cliniral  Journal. 

'^Journal  of  Experimental  Medicine,   UK)"),  vol.  vii,  p.  1. 


SYPHILIS  497 

coarse  muscle  bundles  separated  by  loose  connective  tissue. 
An  injection  into  the  sacrospinal  muscle  always  remains 
intramuscular,  while  the  medicated  solutions  can  readily 
escape  from  the  gluteal  muscles  into  the  loose  connective 
tissue.  Clinically,  it  has  been  established^  in  a  limited 
number  of  cases  of  syphilis  that  ''salvarsan"  injected  into 
the  sacrospinal  muscle  exerts  a  fairly  rapid  and  unmistak- 
ably beneficial  influence  upon  the  secondary  and  tertiary 
manifestations  and  upon  the  Wassermann  reaction  without 
causing  pain  or  other  ill  effects  deserving  serious  considera- 
tion. 

Metallic  mercury  is  administered  intramuscularly  in  the 
form  of  gray  oil;  the  formula  for  making  up  this  combi- 
nation is  as  follows: 

Gm.  or  Cc. 

I^ — Hydrargyri 2.0  3ss 

Unguenti  hydrargyri 0.12  gr.  ij 

Petrolati  liquidi 4.0  3j 

Misce. 

Sig. — From  one  to  two  minims  injected  at  a  dose. 

Gm.  or  Cc. 

I^ — Hydrargyri 1.0  gr.  xv 

Petrolati  liquidi  (carbolized  2  p.  c.)     .      .        10.0  5iiss 

Misce. 
Sig. — Ten  minims  injected  once  a  week.     (Lambkin.) 

Gm.  or  Cc. 

^ — Hydrargyri  salicylatis 1.0  gr.  xv 

Petrolati  liquidi 10.0  3iiss 

Misce. 

Sig. — From  3  to  10  drops  injected  once  a  week  or  once  every  two  weeks. 

(Gottheil.) 

Gm.  or  Cc. 

I^ — Hydrargyri  benzoatis, 

Sodii  chlozidi aa        0.3  gr.  v 

Aquse  destillatae 30.0  5j 

Dissolve  with  the  aid  of  heat  and  then  filter. 

Sig. — Ten  minims  injected  once  or  twice  a  week.     (Gottheil.) 

Gm.  or  Cc. 

I^ — Hydrargyri  ehloridi  mitis 0.3  gr.  v 

Olei  olivse 6.0  3is3 

Misce. 

Sig. — Ten  to  fifteen  minims  introduced  hypodermically. 

1  S.  J.  Meltzer,  On  the  Injection  of  Drugs,  Especially  of  Salvarsan  (Ehr- 
lich),  into  the  Lumbar  Muscles,  Medical  Record,  March  25,  1911,  p.  516. 
32 


498       ARTERIOSCLEROSIS— SYPHILIS— TUBERCULOSIS 

The  succinimide  of  mercury  may  be  given  as  follows: 

Gm.  or  Cc. 

I^ — Hydrargyri  succinimidi 2.0  3ss 

Cocainse  hj^drochloridi 0 .  65  gr.  x 

Aquae  destillatse 45.0  giss 

Misce. 

Sig. — Fifteen  drops  hypodermically  twice  a  week. 

Salvarsan. — A  remedy  for  syphilis  has  been  announced 
which  bids  fair  to  revolutionize  the  treatment  of  this  disease. 
It  is  an  arsenical  compound,  dioxydiamidoarsenobenzol, 
and  is  known  as  '' Salvarsan,"  the  "Ehrlich-Hata  prepara- 
tion/' and  ''606."  The  chemical  composition  of  the  drug 
is  C12H12O2N2AS2,  and  is  expressed  in  the  following  graphic 

formula : 

As     =     As 


OH  OH 

In  connection  with  Weinberg,  Ehrlich  succeeded  in  pro- 
ducing a  dyestuff,  called  trypan-red,  which  cured  absolutely 
every  mouse  infected  with  the  trypanosome  of  sleeping 
sickness.  From  this  fact  he  inferred  the  possibility  of  pro- 
ducing a  specific,  one  injection  of  which  should  destroy  the 
parasites  in  the  human  body.  Although  trypan-red  possesses 
the  power  of  destroying  all  the  trypanosomes  in  the  bodj^ 
of  an  infected  mouse,  it  has  no  effect  on  trypanosomes 
mixed  in  a  test-tube  with  blood.  It  was  soon  discovered 
that  certain  substances  which  have  no  effect  on  the  parasites 
in  the  test-tube  are  so  changed  inside  the  bodj^  that  they 
become  effective.  Trypan-red  either  destroys  all  the  para- 
sites within  the  body  of  the  mouse  by  its  specific  action, 
or  it  destroys  a  few,  and  the  remaining  ones  are  destroyed 
by  the  rapidly  formed  antibodies.  It  was  on  lines  of  this 
experimentation  that  Ehrlich  came  upon  dioxydiamido- 
arsenobenzol (606).  He  calls  the  drugs  that  destroy  living 
parasites  without  injury  to  the  organic  tissue  parasitropic. 
Those   that   destroy   organic   tissue  he  calls  organoti-opic. 


SYPHILIS  499 

Dioxydiamidoarsenobenzol  will  be  classed  among  the  para- 
sitropic  remedies.  It  destroys  the  parasites  in  the  body, 
and  these  dead  parasites  induce  the  formation  of  antibodies 
which  assist  the  action  of  the  drug. 

This  preparation  is  a  yellowish  crystalline  substance,  not 
unlike  iodoform  in  appearance,  and  must  be  kept  in  her- 
metically sealed  ampoules,  for  it  becomes  very  toxic  when 
exposed  to  the  air.  For  administration  it  must  be  handled 
with  the  greatest  care,  and  exact  details  in  the  technique 
must  be  carried  out. 

A  safe  method  of  administration  is  that  of  Wechselmann: 
The  dioxydiamidoarsenobenzol  is  shaken  out  of  its  sealed 
glass  ampoule  and  is  dissolved  by  rubbing  in  a  sterile  agate 
mortar  with  one  to  two  cubic  centimeters  of  10-per-cent. 
caustic  soda  solution.  The  addition  of  glacial  acetic  acid 
drop  by  drop  then  throws  down  a  precipitate  in  the  form  of  a 
fine  yellow  powder.  This  in  the  next  place  is  suspended  in 
one  to  two  cubic  centimeters  of  sterilized  distilled  water, 
and  the  fluid  is  neutralized  by  decinormal  soda  solution 
or  acetic  acid  of  1  per  cent,  strength,  the  reaction  being 
very  carefully  observed  with  litmus  paper.  The  painless- 
ness of  the  injection  depends  upon  the  exactness  of  the  neu- 
tralization. For  this  reason  the  suspension  is  centrifugalized, 
the  fluid  poured  off,  and  the  yellow  sediment  suspended 
in  physiologic  salt  solution.  This  suspension  is  drawn  up 
into  the  syringe  and  slowly  injected  subcutaneously  at  a 
point  below  the  shoulder-blade,  the  place  having  been  pre- 
viously made  aseptic  and  touched  with  tincture  of  iodine. 
A  little  pain  often  continues  for  some  minutes  after  the 
injection,  and  local  lesions  are  not  uncommon. 

Kromayer^  uses  an  emulsion  of  dioxydiamidoarsenobenzol 
in  liquid  petrolatum.  The  drug  is  rubbed  up  with  the  oil  so 
that  one  cubic  centimeter  of  the  emulsion  will  contain  ten 
centigrammes  of  the  remedy.  Kromayer  says  there  is  no 
pain  incident  to  the  administration  of  the  chemical  thus 
prepared.  But  while  the  oil  preparation  gives  little  pain  at 
the  time  of  the  injection,  a  pain  develops  in  three  or  four 

1  Med.  Klinik,  1910,  No.  40. 


500       ARTERIOSCLEROSIS— SYPHILIS— TUBERCULOSIS 

days,  due  to  local  absorption  and  the  inflanmiatory  reaction 
thus  induced  in  the  tissues. 

Ehrlich  recommends  intravenous  injections,  repeated 
several  times  and  followed  after  some  months  bj^  an  intra- 
muscular injection.  The  intravenous  injection  after  the 
method  of  Schreiber  is  as  follows: 

Into  a  graduate  of  250  Cc.  capacity  put  10  to  20  Cc.  of  ster- 
ilized water.  Add  the  required  dose  of  dioxydiamidoarseno- 
benzol  and  mix  thoroughl}^  until  a  clear  solution  results; 
add  steriUzed  water  or  normal  salt  solution  to  the  100-Cc. 
mark;  then  add  for  each  0.1  Gm.  of  dioxydiamidoarseno- 
benzol  0.7  Cc.  of  normal  sodium  hydrate  solution  and  mix 
well  until  the  precipitate  is  thoroughly  redissolved.  If  after 
thorough  mixture  the  solution  is  not  clear,  add  a  few  drops 
of  the  sodium  hydrate  solution  until  it  becomes  clear,  and 
then  add  sufficient  normal  salt  solution  to  make  200  to 
250  Cc.  The  fluids  used  must  all  be  warm.  The  alkaline 
mixture  is  then  ready  for  injection. 

It  should  be  understood  that  all  the  chemicals  used  in 
the  preparation  of  the  material  for  injection  are  to  be  kept 
thoroughly  sterile.  The  treatment  consists  of  a  single  injec- 
tion of  0.3  to  0.9  Gm.  (5  to  14  grains)  of  dioxydiamidoarseno- 
benzol  in  solution,  given  intravenously  or  into  the  gluteal  or 
pectoral  muscles. 

A  large  number  of  patients  have  been  successfully  treated 
with  this  preparation.  It  has  been  used  in  the  treatment  of 
syphilis  in  aU  stages,  from  the  primary  chancre  to  the  deep 
specific  lesions  of  the  central  nervous  system.  It  possesses 
apparently  the  peculiar  property  of  killing  and  extermina- 
ting the  Treponema  pallidum  fSpirochsete  pallida)  wherever 
it  is  to  be  found  in  the  lesions.  It  is  said  to  cure  syphilis 
in  all  three  stages.  The  immediate  effect  of  this  latest 
antisyphilitic  agent  is  manifest  in  its  prompt  action  on 
syphilides,  mucous  patches,  gummata,  and  chancre.  The 
drug  relieves  the  shooting  j)ain,  the  girdle  sensation,  and  the 
tabetic  crises  almost  immediately.  But  it  cannot  he  expected 
to  regenerate  destroyed  tissues. 

In  the   diagnosis  of   syphilis,   Ehrlicli   lays   great   stress 


TiBERCULOSIS  501 

upon  the  Wasserinann  reaction  as  a  conclusive  factor  in 
determining  whether  or  not  salvarsan  shall  be  injected. 
A  positive  reaction  proves  the  presence  of  syphilis,  and  the 
injection  of  salvarsan  is  advised.  Very  often  a  positive 
Wassermann  reaction  becomes  negative  after  one  injection 
of  salvarsan,  and,  on  the  other  hand,  the  reaction  may  con- 
tinue positive  although  all  symptoms  indicative  of  the  disease 
have  subsided  or  disappeared. 

General  Treatment. — Patients  suffering  from  syphilitic 
diseases  of  the  stomach  should  be  kept  at  rest,  preferably 
in  bed.  Their  food  should  be  of  a  simple,  unirritating  kind, 
its  precise  character  depending  upon  the  severity  of  the 
symptoms.  In  very  severe  cases  it  may  be  necessary  to 
resort  to  rectal  alimentation.  In  any  case  it  is  advisable 
to  inaugurate  the  treatment  by  a  milk  diet.  As  the  condition 
of  the  patient  improves,  the  quantity  and  variety  of  the 
food  may  be  slowly  increased,  and  jellies  flavored  with  lemon 
and  sweetened,  junket,  eggs  hghtly  cooked  or  beaten  up 
with  milk,  custards  or  tapioca  pudding,  may  be  permitted. 
This  regimen  may  be  followed  later  by  bread  and  butter, 
fish,  chicken,  rabbit,  or  veal.  No  meat  should  be  allowed 
for  at  least  six  months. 

The  bowels  should  be  carefully  regulated,  and  for  the 
control  of  constipation  resort  should  be  had  to  saline 
cathartics. 

TUBERCULOSIS 

Gastric  tuberculosis  is  a  very  rare  condition,  and  when 
present  it  is  usually  secondary  to  or  associated  with  tuber- 
culosis of  other  organs. 

Forms. — Three  forms  of  tuberculosis  of  the  stomach  have 
been  recognized,  namely:  (1)  Mihary  tuberculosis — always 
secondary  to  general  miliary  tuberculosis;  it  cannot  be 
diagnosticated,  and  is  therefore  not  amenable  to  treatment. 
(2)  Tuberculous  ulcer.  This  occasionally  produces  disturb- 
ances similar  to  those  produced  by  peptic  ulcer.  Hemor- 
rhages are  not  infrequent,  and  perforation  is  more  likely 


502       ARTERIOSCLEROSIS— S  YPHILIS—T  UBERC  ULOSIS 

to  occur  than  with  peptic  ulcer.  Tuberculous  ulcer  has  been 
attributed  to  the  swallowing  of  tuberculosis  sputum.  It 
may  also  result  from  infection  through  the  blood  and  lymph 
routes.  The  treatment  is  that  of  peptic  ulcer.  (3)  Tuber- 
culous granulation  tumors — located  on  the  pylorus  or  in 
the  region  of  the  pylorus.  The  symptoms  resemble  those 
of  gastric  carcinoma,  and  the  treatment  is  the  same  as  for 
the  latter.  Success  has  followed  resection  in  tuberculous 
stenosis  of  the  pylorus. 

Ellis^  reports  two  cases  of  tuberculous  ulcer  of  the  stomach. 
One  had  extensive  ulcerated  tuberculosis  of  both  lungs  and 
likewise  tuberculous  ulcers  in  the  ileum  and  colon.  In  the 
floor  of  most  of  the  ulcers  gray  or  yellow  tubercles  were 
found.  The  other  case  was  a  chronic  adhesive  tuberculous 
peritonitis,  with  multiple  tuberculous  fistulse  in  the  left 
inguinal  and  trochanteric  regions.  On  the  serous  surface 
or  peritoneal  coating  of  the  stomach,  scattered  irregularly 
over  the  entire  viscus,  were  numerous  tubercles  of  varjdng 
size. 

Treatment. — The  treatment  of  tuberculosis  of  the  stomach 
is  the  treatment  of  tuberculosis  localized  elsewhere  in  the 
body. 

1  New  York  Medical  Journal,  March  12,  1910. 


CHAPTER    XXIII 

TUMORS  OF  THE  STOMACH:  CARCINOMA  —  SARCOMA  — 
FIBROMA  —  FIBROMYOMA  —  LIPOMA  —  ADENOMA  —  PAPIL- 
LOMA —  POLYPI  —  HERNIA  EPIGASTRICA 

CARCINOMA. 

Etiology.- — Incidence. — Of  all  the  viscera  of  the  body,  the 
stomach  is  most  frequently  the  seat  of  carcinoma.  Of  the 
total  number  of  carcinoma  cases  reported,  from  40  to  45 
per  cent,  are  said  to  be  cancer  of  the  stomach.  It  occurs 
more  frequently  in  males  than  in  females.  Many  writers, 
among  them  Haeberlin,  have  reported  carcinoma  to  be  on 
the  increase.  Of  all  the  cases  reported  during  the  period 
between  1877  and  1886,  Haeberlin  found  41  per  cent,  to 
be  carcinoma  of  the  stomach.  According  to  Wyss  the  death 
rate  from  cancer  is  nearly  2  per  cent,  of  the  totalmortality; 
Bryant  states  that  in  New  York  City  for  the  ten  years 
immediately  preceding  1896,  it  was  2.17  per  cent,  of  the 
total  mortality.  The  frequency  of  this  disease  varies  in 
different  countries.  There  are  certain  regions  in  which 
it  seldom  occurs.  Griesinger  states  that  he  has  never  seen 
a  case  of  cancer  of  the  stomach  in  Egypt,  while  Heinemann 
reports  that  he  saw  only  one  case  in  Vera  Cruz  during  a 
period  of  six  years.  Owing  to  the  unreliability  of  registra- 
tion statistics  it  is  very  difficult  to  estimate  whether  cancer 
is  increasing  or  not.  When  we  consider  the  advances  that 
have  been  made  in  medical  science  in  the  way  of  refinement 
of  diagnosis,  it  is  evident  that  carcinoma  is  more  frequently 
discovered  and  differentiated  from  non-malignant  growths 
than  was  formerly  the  case.  This  of  itself  would  account, 
in  a  measure,  for  the  apparent  increase  in  the  prevalence 
of  the  disease. 


504  TUMORS  OF  THE  STOMACH 

Age. — Regarding  the  age  at  which  gastric  carcinoma 
occurs  most  frequently,  Brinton  has  collected  some  inter- 
esting data.  In  600  cases  the  year  of  death  averaged  fifty — 
two-sevenths  of  these  between  fifty  and  sixty.  This  writer 
places  the  maximum  liability  between  sixty  and  seventy. 
Under  twenty,  the  whole  risk  is  less  than  one-fiftieth  of 
what  it  is  between  twenty  and  thirty.  Lebert  gives  us 
the  following  figures  as  to  the  age  at  which  cancer  of  the 
stomach  occurs:  Under  thirty  years,  1  per  cent.;  thirty  to 
forty  years,  17.6  per  cent.;  forty  to  sixty,  60.7  per  cent.; 
sixty  to  seventy,  16.3  per  cent;  above  seventy,  4.4  per  cent. 

Heredity. — The  influence  of  heredity  as  a  predisposing 
cause  of  cancer  of  the  stomach  is  still  an  open  question. 
The  occurrence  of  cancer  in  one  or  more  of  the  offspring 
of  carcinomatous  parents  has  been  noted,  but  not  with 
marked  frequency.  Cancer  has  been  known  to  attack 
persons  whose  health  up  to  the  time  of  the  attack  had  been 
remarkably  good.  Among  predisposing  if  not  strictly 
etiologic  factors,  gastric  ulcer,  the  cicatrix  of  an  ulcer, 
achylia  gastrica,  and  chronic  gastritis  may  be  mentioned. 
The  mode  of  living  is  not,  however,  responsible  for  the  devel- 
opment of  cancer  of  the  stomach,  nor  can  traumatism  be 
said  to  be  specially  productive  of  this  form  of  malignancy. 
Injury,  however,  may  stimulate  into  activity  an  incipient 
or  dormant  carcinoma.  The  infectious  nature  of  cancer 
still  remains  to  be  proved. 

Brinton  explains  the  occurrence  of  cancer  of  the  cardia 
and  pylorus  as  follows:  The  muscle  fibres  of  these  two 
orifices  have  more  work  to  do  than  the  rest  of  the  stomach, 
since  the  connective  tissue  enclosed  in  them  is  subject  to 
contraction  and  distention.  This  functionating  process 
induces  greater  nutrition  of  these  parts,  which  may  give  rise 
to  a  proliferation  of  the  glandular  tissues,  thus  foi-ming  a 
neoplasm.  Inflanmiatory  conditions  of  the  mucous  lining 
of  the  stomach  have  been  considered  a  contributing  factor 
in  the  etiology  of  the  disease. 

Pathology. — (lastric  cancer  consists  of  atyjMcal  o]Mthelial 
proliferations  having  their  starting  point  in  the  glandular 


CARCINOMA  505 

cells  and  the  epithelial  lining  of  the  excretory  ducts  of  the 
glandular  tissue  of  the  gastric  mucous  membrane.  It 
develops  into  a  tumor  of  varying  size,  sometimes  attaining 
such  dimensions  as  to  occlude  the  lumen  of  the  stomach. 
Cancer  occasionally  consists  of  more  or  less  flat  granula- 
tions and  excrescences.  It  shows  a  tendency  toward 
necrotic  disintegration  with  an  ulcerated  surface,  productive 
of  hemorrhage. 

Gastric  carcinoma  forms  metastases  in  the  lymphatic 
vessels  with  great  rapidity.  The  glands  in  the  neighborhood 
of  the  stomach  likewise  become  rapidly  involved,  and  there 
are  metastases  in  the  omentum  as  well  as  carcinomatous 
degeneration  of  the  entire  peritoneum.  The  carcinomatous 
masses  frequently  penetrate  the  bloodvessels,  as  a  result 
of  which  there  are  metastatic  cancers  in  the  abdominal 
organs,  particularly  the  liver,  and  not  infrequently  metas- 
tases develop  in  the  lungs,  the  heart,  and  the  rectum. 

Cancers  differ  widely  in  regard  to  rapidity  of  growth  and 
degree  of  malignancy.  Some  grow  with  alarming  rapidity, 
while  others  may  remain  dormant  or  nearly  stationary 
for  a  long  period  of  time. 

Gastric  carcinoma  has  been  found  to  be  located  most 
frequently  in  the  pyloric  portion  of  the  stomach,  and  when 
so  located  occasions  nearly  always  a  stenosis  of  the  pylorus. 
The  location  second  in  frequency  is  the  lesser  curvature 
of  the  stomach.  Some  writers  have  stated  that  cancer  of 
the  pylorus  constitutes  50  per  cent,  of  all  cases  of  gastric 
cancer,  while  30  to  40  per  cent,  have  been  found  to  occupy 
the  lesser  curvature.  Next  in  order  of  frequency  are  cancers 
of  the  cardiac  portion  of  the  stomach;  these  constitute  9 
per  cent.;  they  are  accompanied,  as  a  rule,  by  stenosis 
of  the  cardia  and  of  the  esophageal  entrance.  Cancer 
occurs  but  rarely  in  the  anterior  or  posterior  wall  of  the 
stomach.  Diffuse  carcinomatous  infiltration  of  the  stomach 
takes  place  in  about  6  per  cent,  of  the  total  number  of 
cases. 

Forms. — The  forms  of  gastric  carcinoma,  in  the  order  of 
their  frequency,  are:  Medullary  carcinoma,  adenocarcinoma, 


506  TUMORS  OF  THE  STOMACH 

gelatinous  carcinoma,  and  scirrhus  (carcinoma,  simple  or 
fibrous) . 

Medullary  Carcinoma. — Medullary  carcinomata  are  large, 
flat,  soft  masses  projecting  above  the  gastric  mucous  mem- 
brane. These  malignant  growths  are  very  rich  in  vessels 
and  cells,  but  possess  very  httle  connective  tissue  stroma. 
The  spongy  mass,  on  section,  is  seen  to  be  whitish  yellow. 
iNIedullary  carcinoma  is  usually  attended  by  frequent 
hemorrhages.  Secondary  metastases  are  very  frequent 
compUcations. 

Adenocarcinoma. — The  adenocarcinoma,  or  gastric  epithe- 
lioma, consists  of  soft  tumors  with  marked  nodules.  At 
first  there  are  pseudoglandular  tubuli,  surrounded  b}^  con- 
nective tissue  infiltrated  with  white  blood  corpuscles;  but 
as  the  neoplasm  grows  older  the  regular  arrangement  of 
the  epithelium,  distinguishable  in  the  earlier  stage,  becomes 
lost,  and  the  tubular  spaces  are  filled  with  cells,  the  result 
of  epithelial  proliferation. 

Gelatinous  or  Colloid  Carcinoma. — The  gelatinous  or  col- 
loid carcinoma  is  the  result  of  mucous  degeneration  of 
epithelioma  and  of  medullary  carcinoma.  The  growth 
assumes  a  gelatinous  appearance  which  is  very  character- 
istic. According  to  Einhorn,  the  stroma  of  the  tumor 
surrounds  transparent  gelatinous-looking  masses  which  con- 
sist of  the  cancer  cells  in  a  condition  of  colloid  degeneration. 
On  cutting  and  scraping,  a  true  cancer  juice  does  not  exude, 
but,  instead,  gelatinous  fragments. 

Scirrhus  Carcinoma. — The  scirrhus  carcinoma  is  made  up 
of  an  abundance  of  connective  tissue.  The  stroma,  sur- 
rounded by  dense  connective-tissue  fibres,  contains  compara- 
tively very  few  cells,  so  that  the  neoplasm  has  the  character 
of  a  firm,  compact  substance.  It  is  somewhat  difficult  to 
cut,  and  on  section  presents  a  cartilaginous  tissue  of  a  light 
color,  interspersed  with  yellow  or  red  spots.  There  is  but 
slight  tendency  to  formation  of  secondary  growths  from  this 
variety  of  cancer. 

Complications. — The  portion  of  the  gastric  nuicous  mem- 
brane that   is  not   directly  involved  in  the  carcinomatous 


CARCINOMA  507 

process  may  functionate  in  a  perfectly  normal  manner, 
especially  during-  the  initial  stage  of  the  disease.  This, 
however,  does  not  continue  for  any  great  length  of  time, 
owing  to  the  progressive  atrophic  changes  which  take  place 
in  the  gastric  mucous  membrane.  In  cases  of  gastric  car- 
cinoma complicated  with  pyloric  stenosis  and  stagnation, 
a  frequent  feature  is  chronic  gastritis  with  marked  secretion 
of  mucus. 

Complications  of  gastric  carcinoma  may  consist  of  adhe- 
sions to  or  rupture  into  neighboring  organs,  such  as  the 
intestine,  gall-bladder,  pancreas,  and  liver.  Perforation 
into  the  peritoneal  cavity  is  rarely  met.  Other  rare  com- 
plications are  rupture  into  the  pleural  cavity,  subphrenic 
abscess,  pj^opneumothorax,  and  free  bleeding  from  the 
cancer  itself  Agastric  hemorrhage). 

Symptomatology. —  The  earliest  symptoms  of  carcinoma  of 
the  stomach  are  pressure  and  fulness  after  eating.  This  mild 
sensation  is  superseded  sooner  or  later  by  pain  of  varying 
intensit}';  the  pain  may  be  felt  in  the  region  of  the  stomach, 
directly  in  front  or  to  the  right  or  left  of  the  median  line, 
or  it  may  be  felt  in  the  dorsal  region.  Pain  is  not  a  constant 
symptom,  however;  it  is  often  absent,  particularly  when  the 
cancer  is  situated  on  the  lesser  curvature.  The  patient  is 
frequently  annoyed  by  eructations  due  to  decomposition  of 
the  food  mass  within  the  stomach.  Anorexia  is  among  the 
early  sj^mptoms,  the  patients  manifesting  a  distaste  for  meat. 
In  a  few  cases  the  normal  appetite  has  been  known  to  con- 
tinue for  a  long  time  after  the  appearance  of  the  initial 
symptoms;  and  in  rare  cases  there  is  a  markedly  increased 
appetite.  As  a  rule  the  patients  complain  of  weakness 
and  are  disinclined  or  unable  to  work.  They  lose  flesh 
rapidly.  These  symptoms  progress  until  nausea  and  vomit- 
ing become  troublesome  features.  Vomiting  depends  largely 
upon  the  location  of  the  neoplasm;  cancer  of  the  pylorus  is 
nearly  always  accompanied  by  vomiting,  owing  to  stenosis 
of  the  pyloric  exit.  In  cancer  of  the  greater  or  lesser 
curvature  there  may  be  no  vomiting  at  any  time  through- 
out the  course  of  the  disease.     When  vomiting  becomes 


508  TUMORS  OF  THE  STOMACH 

severe,  great  thirst  is  experienced,  and  a  marked  diminu- 
tion in  the  quantity  of  urine  excreted  is  noted. 

The  inabiUty  to  assimilate  food  results  in  rapid  loss  of 
weight.  This  condition  becomes  so  marked  that  patients 
frequently  die  of  inanition. 

In  carcinoma  of  the  cardia  the  subjective  symptoms  are 
more  insidious.  Difficulty  in  deglutition  is  one  of  the  first 
distinct  signs  confirmatory  of  the  diagnosis;  it  results  from 
occlusion  of  the  lower  end  of  the  esophagus.  The  patient 
finds  that  he  cannot  swallow  solid  foods  with  ease;  he 
experiences  a  sensation  of  the  food  "sticking  fast"  before 
it  enters  the  stomach.  Pain  results  from  the  movement 
of  the  food  through  the  stenotic  cardiac  orifice. 

As  the  disease  progresses  the  patients  acquire  a  charac- 
teristic cachectic  appearance — loss  of  flesh,  and  sallow  com- 
plexion. In  the  later  stages  of  the  disease  anemia  super- 
venes; the  percentage  of  hemoglobin  and  the  number  of 
red  blood  cells  are  much  below  normal.  The  anemic  con- 
dition may  be  due  to  hemorrhages,  to  insufficient  nutrition, 
or  to  the  effect  of  toxins  from  the  carcinoma.  Hemolytic 
substances  have  been  discovered  in  the  gastric  contents  of 
carcinomatous  patients.  Not  infrequently  there  is  edema 
in  the  region  of  the  ankles. 

Diagnosis. — Examination  of  the  stomach  in  a  tj^pical  case 
of  gastric  carcinoma  reveals  a  tumor  of  varjdng  location, 
size,  and  shape.  Tumors  of  the  pylorus  are  usually  located 
to  the  right  of  the  median  line;  with  the  stomach  in  the 
normal  position  it  is  impossible  to  palpate  such  tumors, 
owing  to  overlapping  by  the  liver;  when  not  concealed  by 
the  liver  they  may  be  felt  below  the  right  l^order  of  the 
ribs,  protruding  during  deep  inspiration.  When  the  stomach 
has  descended  it  may  be  palpated  at  varying  distances 
below  the  ribs.  Tumors  of  the  lesser  curvature  may  like- 
wise be  so  covered  by  the  liver  as  to  render  palliation  im- 
possible. The  usual  site  of  tumors  of  the  greater  curvature 
and  of  the  fundus  is  at  the  level  of  the  umbilicus  or  below  it. 
These  differ  from  neoplasms  of  the  pylorus  in  the  absence 
of  symptoms  of  obstruction  produced  by  pyloric  stenosis. 


CARCINOMA  509 

When  the  neoplasms  have  formed  adhesions  to  neighboring 
organs  of  the  abdominal  cavity,  they  are  found  to  be 
immovable  or  only  slighth'  movable  on  palpation.  Motor 
insufficiency  supervenes  in  cases  of  cancer  of  the  pylorus, 
in  proportion  to  the  degree  of  stenosis  present. 

An  examination  of  the  stomach  contents  in  typical  cases 
of  gastric  carcinoma  reveals  the  presence  of  lactic  acid  and 
the  lactic  acid  bacilli  of  Boas-Oppler  (Fig.  7);  such  cases  are 
marked  by  the  absence  of  free  hydrochloric  acid.  The  color 
of  the  gastric  contents  is  freciuently  brown  or  of  a  coffee- 
ground  appearance,  owing  to  hemorrhages  from  the  carcino- 
matous growth.  ^Microscopicall}^,  blood  and  pus  are  both  seen 
in  the  gastric  contents  in  cases  of  ulcerated  carcinomata. 
Occult  hemorrhages  are  frequently  demonstrated  by  exami- 
nation of  the  feces.  (For  the  peptid  and  the  hemolytic  tests 
see  pages  63  and  65.) 

The  most  frequent  seat  of  metastasis  is  the  liver,  which 
usually  shows  marked  enlargement.  When  the  carcinoma- 
tous growth  has  progressed  for  a  considerable  length  of 
time  the  supraclavicular  glands  of  the  left  side  may  be 
enlarged. 

Carcinomata  are  found,  however,  to  vary  in  a  marked 
degree  from  the  type  here  presented.  The  latent  stage  of 
cancer  is  often  prolonged.  The  tumor  may  not  be  discovered ; 
subacidity  or  achylia  may  be  diagnosticated  from  an  exami- 
nation of  the  gastric  contents,  with  no  further  objective 
symptoms  which  would  point  to  the  presence  of  malignant 
growth.  Differing  from  our  typical  case,  free  hydrochloric 
acid  may  be  present  for  a  long  time  after  the  initiation  of 
the  cancerous  process,  while  the  appearance  of  lactic  acid 
msLY  be  long  delayed  or  never  present.  In  such  cases  it  is 
extremely  difficult  and  often  impossible  to  make  a  diagnosis 
with  certainty.  Exploratory  laparotomy  is  sometimes  justi- 
fiable. 

Carcinoma  of  the  cardia,  as  a  rule,  offers  resistance 
more  or  less  marked  to  the  passage  of  a  sound;  especially 
is  this  the  case  when  the  lower  portion  of  the  esophagus  is 
involved. 


510  TUMORS  OF  THE  STOMACH 

Treatment. — The  treatment  of  carcinoma  of  the  stomach 
is  essentially  sm'gical.  The  physician  should,  therefore, 
endeavor  to  ascertain  precisely  the  chances  offered  by  oper- 
ation in  each  individual  case  before  employing  internal 
medication,  which  is  at  best  palliative  and  in  no  sense 
curative.  As  soon  as  the  diagnosis  of  cancer  of  the  stomach 
is  confirmed,  the  case  should  be  referred  to  the  surgeon 
without  delay.  The  operation  for  this  condition  consists 
of  total  or  partial  resection.  According  to  some  writers, 
it  is  accompanied  by  a  mortality  of  about  27  per  cent. 
Billroth,  in  1878,  showed  the  possibility  of  excising  carcino- 
matous growths  in  the  region  of  the  pylorus.  Since  that  time 
surgeons  in  the  various  countries  have  contributed  to  the 
development  of  this  heroic  method  of  treatment.  By  total 
resection  of  the  tumor,  done  early  enough,  it  is  often  possible 
to  effect  a  radical  cure.  If  the  diagnosis  of  gastric  cancer 
could  be  made  sufficiently  early,  before  metastases  had 
formed  or  marked  glandular  involvement  taken  place,  the 
possibility  of  radical  cure  would  be  very  considerable. 
Gastric  cancer,  however,  can  rarely  be  diagnosticated  before 
it  has  formed  adhesions  with  other  organs  or  before  metas- 
tatic deposits  have  taken  place  elsewhere. 

The  operation  for  partial  gastrectomy  and  pylorectomy 
was  performed  by  C.  H.and  W.  J.  Mayo,^  between  April  21, 
1897,  and  January  26,  1910,  266  times;  there  were  34  deaths, 
making  a  mortality  percentage  of  12.4.  Forty-two  of  these 
operations  were  performed  for  benign  tumors,  or  ulcers,  or 
in  cases  the  diagnosis  of  which  was  not  microscopically  estab- 
lished. The  remaining  224  operations  were  for  carcinoma 
involving  the  pyloric  end  of  the  stomach,  the  patients  being 
classified  as  follows: 

Males 163 

Females 61 

Age  of  olrlo.st 81 

Age  of  youngest. 30 

Average  age 53 

'  Radical  Operation  for  Cancer  of  the  Pyloric  End  of  the  Stomach,  Journal 
of  the  Ainorifan  Modifal  Assoriation,  May  14,  IDIO,  p.  1608. 


CARCINOMA  511 

Patients  operated  on  over  five  years  ago 50 

Of  these  50,  the  {)rescnt  condition  of  39  is  known,  and  of  these 
8  are  alive  and  well  (one  eight  years  two  and  one-half  months; 
one  eight  years;  one  seven  years  two  months;  one  six  years;  one 
six  years  eleven  months;  one  five  years  three  and  one-half 
months;  one  five  years — has  since  died  of  recurrence). 

Patients  operated  on  over  four  years  ago 85 

Of  these  85,  the  present  condition  of  64  is  known,  and  of  these 
13  are  alive  and  well. 

Patients  operated  on  over  three  years  ago 117 

Of  these  117,  the  present  condition  of  S8  is  known,  and  of 
these  18  are  alive  and  well. 

Patients  operated  on  less  than  three  years  ago     .  .      .      .      107 

When  cancerous  metastases  are  discovered  in  other  organs 
(Uver,  glands) ;  when  adhesions  have  formed,  which  may  be 
ascertained  by  finding  the  tumor  immovable  on  palpation; 
when  the  tumor  has  attained  a  large  size ;  when  high  degrees 
of  anemia  or  cachexia  are  present,  or  in  extreme  old  age, 
radical  operations  for  cancer  are  strictly  contraindicated. 
In  such  conditions  as  these  any  operative  interference  must 
needs  be  only  palliative — to  permit  of  greater  facility  in 
the  introduction  of  food  into  the  digestive  tract,  or  to 
diminish  as  much  as  possible  the  irritating  effect  of  food 
upon  the  affected  area.  For  this  purpose  either  a  gastros- 
tomy or  a  gastroenterostomy  may  be  performed,  the  former 
in  malignant  affections  of  the  cardiac  orifice  or  of  the 
esophagus,  the  latter  in  malignant  affections  of  the  pylorus 
or  its  immediate  neighborhood.  By  gastrostomy  an  open- 
ing is  established  between  the  stomach  and  the  abdominal 
wall  for  the  direct  introduction  of  food.  Gastroenteros- 
tomy consists  in  the  establishment  of  a  new  communication 
between  the  stomach  and  the  small  intestine,  so  that  the 
contents  of  the  stomach  will  not  need  to  pass  through  the 
pylorus.  According  to  Einhorn,  this  operation  is  indicated 
as  soon  as  malignant  trouble  with  ischiochymia,  or  stagni  - 
tion  of  the  gastric  contents,  is  diagnosticated,  especially  if 
the  radical  operation  does  not  appear  to  be  feasible.  Gastic  - 
enterostomy  has  been   the  means  of  prolonging  life  aid 


512  TUMORS  OF  THE  STOMACH 

rendering  the  patient  more  comfortable  than  would  have 
been  possible  by  any  other  mode  of  treatment. 

The  number  of  cures  might  be  greatly  increased  if  opera- 
tive treatment  were  instituted  early,  not  only  for  estab- 
lished cases  of  cancer,  but  also  for  those  diseases  which  have 
been  found  to  predispose  to  cancer,  such  as  gastric  ulcer 
and  pyloric  stenosis.  An  exploratory  operation  should  be 
undertaken  in  all  cases  in  which  there  is  the  least  suspicion 
of  malignancy;  this  course  is  becoming  more  and  more 
justifiable  since  such  a  high  degree  of  skill  and  compara- 
tively low  mortality  have  been  achieved  by  modern  surgery. 
Should  operation  be  undertaken  in  cases  of  chronic  ulcer 
and  pyloric  stenosis,  there  seems  little  reason  to  doubt  that 
many  a  latent  carcinoma  would  be  exposed  and  a  complete 
cure  result.  In  determining  the  advisability  of  operation 
in  cases  of  carcinoma  of  the  stomach  the  physician  should 
bear  in  mind  the  following  considerations: 

1.  The  general  condition  of  the  patient.  A  certain  degree 
of  vigor  is  necessary  for  recovery  from  operation.  Cachexia 
is  not  necessarily  a  contraindication;  but  if  the  cachectic 
condition  be  severe,  operation  offers  but  little  hope  of 
recovery. 

2.  Carcinomata  of  the  pylorus  or  of  the  lesser  curvature 
prohferating  toward  the  pylorus  are  the  cases  best  adapted 
to  resection.  Resection  is  impossible  in  carcinoma  of  the 
cardia. 

During  an  exploratory  laparotomy,  should  the  surgeon 
find  that  a  successful  resection  is  impossible,  there  remains 
to  him,  as  stated  above,  the  choice  of  gastrostomy  or  gastro- 
enterostomy. 

Internal  Treatment. — Internal  or  palliative  treatment  is  indi- 
cated in  those  cases  which,  after  careful  study  and  examina- 
tion, are  found  not  to  be  amenable  to  surgery.  Medicinal 
treatment  must  proceed  along  symptomatic  lines.  An 
endeavor  should  be  made,  on  the  one  hand,  to  retard  or 
inhibit  the  growth  of  the  neoplasm,  while  on  the  other  the 
subjective  symptoms  of  the  patient  should  be  relieved  to  the 
greatest  possible  extent.    Complete  rest,  both  physical  and 


CARCINOMA  513 

mental,  should  be  procured  for  the  patient.  He  should 
occupy  the  recumbent  position  as  much  as  possible,  and 
retire  early  at  night,  since  physical  rest  conserves  the  heat 
of  the  body;  in  this  way  the  nutrition  may  be  much  more 
advantageously  maintained. 

Diet  is  of  first  importance  in  the  internal  treatment  of 
carcinoma  of  the  stomach.  Of  necessity  small  in  quantity, 
it  should  be  limited  to  articles  of  food  with  a  high  nutritious 
value;  food  containing  the  greatest  number  of  calories, 
and  which  is  at  the  same  time  non-irritating  in  its  nature, 
should  be  prescribed. 

The  regimen  for  a  cancer  patient  should  be  of  such  variety 
as  to  keep  the  appetite  stinmlated  as  long  as  possible. 
Anorexia  is  found  to  be  the  greatest  impediment  to  the 
nutrition  of  these  patients.  Owing  to  the  tendency  to  stag- 
nation of  the  food  mass  in  the  stomach,  and  consequent 
fermentation,  the  meals  should  be  small  and  frequent. 
The  character  of  the  diet  should  be  adapted  as  largely  as 
possible  to  the  condition  of  the  gastric  secretion — free 
hydrochloric  acid  being  regarded  as,  to  a  certain  extent, 
an  indicator  for  the  prescription  of  proteins.  The  reader  is 
referred  to  the  chapter  on  Subacidity  and  Anacidity  for 
dietary  measures  covering  those  conditions  of  secretion. 
The  question  of  motor  disturbance  should  be  kept  in  mind, 
and  in  the  presence  of  marked  stenosis  the  diet  should  be 
that  laid  down  for  the  treatment  of  motor  insufficiency  of 
the  second  degree.  In  all  cases  of  cancer  of  the  stomach 
the  diet  should  be  of  hquid  or  semiliquid  consistency;  the 
necessity  for  this  is  greater  in  the  more  marked  stenoses 
of  the  pylorus  and  in  cases  with  a  tendency  to  hemorrhage. 
Of  the  liquid  nutriments,  milk  occupies  the  first  place;  it 
may  be  prescribed  very  much  according  to  the  desires  of 
the  patient — alone  or  with  tea,  coffee,  and  cocoa,  or  legumi- 
nous flours.  Should  milk  become  distasteful,  buttermilk, 
sour  milk,  kefir,  milk  of  almonds,  milk  soups,  all  form 
agreeable  substitutes.  Tastily  prepared  soups  made  from 
leguminous  flours,  eggs  and  butter,  vegetable  purees,  flour 
puddings  with  fruit  sauces,  malt  extract  free  from  fermenta- 
33 


514  TUMORS  OF  THE  STOMACH 

tive  processes,  constitute  valuable  dietetic  agents  in  this 
condition.  Next  to  niilk,  eggs  are  most  suitable  for  these 
patients;  thej"  may  be  prescribed  soft  boiled,  scrambled,  as 
omelets,  or  raw  beaten  up  with  sugar  and  wine. 

Fat  may  be  prescribed  in  large  quantities  so  long  as  the 
fermentative  process  in  the  stomach  is  not  too  pronounced; 
it  should  be  in  the  form  of  butter,  oUve  oil,  or  chocolates  rich 
in  fat.  Meat  should  be  given  thoroughly  boiled  or  roasted, 
and  finely  divided,  preferably  in  the  form  of  hashed  meat. 
All  meats  may  be  permitted  to  these  patients  except  those 
which  are  very  rich  in  fat,  as  goose  or  duck.  Should  meat 
become  distasteful,  meat  jelHes  may  be  tried;  or,  if  the 
patient's  repugnance  to  meat  in  any  form  is  marked,  it  would 
be  weU  to  omit  it  altogether  from  the  dietary  for  a  few  days. 
Light  cheese  may  be  prescribed.  Zwieback,  biscuits,  and 
toast  must  be  softened  before  being  taken.  All  vegetables 
should  be  served  in  the  form  of  puree. 

The  consistency  of  the  food  to  be  administered  should 
depend  almost  entirel}"  upon  the  degree  of  stenosis  of  the 
pylorus;  when  little  or  no  pyloric  stenosis  exists,  the  patient 
may  be  permitted  to  partake  of  some  solid  food. 

The  habits  of  Ufe  and  the  desires  and  tastes  of  the  patient 
should  not  be  disregarded  entirely  in  prescribing  diet. 
Various  kinds  of  dehcacies  may  be  incorporated  in  the  bill 
of  fare.  The  mental  impression  produced  by  the  addition 
of  a  few  luxuries,  as  well  as  the  preparation  and  serving  of 
food  in  an  attractive  manner,  is  bound  to  have  a  favorable 
effect  upon  the  patient.  Monotony  in  diet  should  be  care- 
fully avoided,  so  as  to  keep  up  a  fair  appetite  and  counteract 
as  far  as  possible  the  distaste  for  food  which  is  too  often  a 
characteristic  symptom  of  the  disease.  I  would  say,  then, 
that  a  patient  without  marked  stenosis  of  the  pylorus  may 
partake  of  a  wide  range  of  food  so  long  as  the  various  dietetic 
articles  agree  with  him.  It  is  often  possible  to  keep  the 
patient  fairly  well  nourished  for  a  considerable  length  of 
time.  The  greatest  obstacle  is  encountered  with  that  class 
of  patients  whose  financial  circumstances  will  not  permit 
of  such  a  varied  diet  as  outlined. 


CARCINOMA  515 

In  marked  stenosis  of  the  pylorus  the  food  should  be 
exclusively  liquid  or  semiliciuid.  When  vomiting  is  a 
troublesome  feature  the  food  should  be  given  in  small 
quantities.  The  nutritive  value  of  liquid  diet  may  be 
enhanced  by  the  addition  of  such  preparations  as  somatose, 
sanatogen,  plasmon,  or  nutrose,  which  increase  the  calorific 
value  of  an  otherwise  simple  liquid  diet.  Coffee  or  tea 
with  the  addition  of  milk,  or  mineral  waters  with  a  small 
percentage  of  carbon  dioxide,  may  be  used  as  beverages. 

In  case  of  gastric  hemorrhage  resulting  from  cancer  of  the 
stomach,  the  patient  should  assume  the  recumbent  position. 
The  diet  in  this  condition  should  be  as  prescribed  in  the 
chapter  on  Gastric  Hemorrhage. 

In  cases  in  which  it  is  extremely  difficult  to  maintain 
nutrition  by  oral  feeding,  as  in  severe  pyloric  stenosis  with 
troublesome  vomiting,  nutritive  enemata  should  be  employed, 
but  only  as  an  adjunct  to  oral  feeding.  Exclusive  rectal 
alimentation  should  not  be  attempted,  even  for  a  few  days, 
since  it  has  been  found  that  inanition  results  more  rapidly 
under  this  regimen  than  with  even  a  minor  degree  of  oral 
alimentation  alone: 

Diet  in  Caecinoma  of  the  Stomach 

Calories. 
Breakfast.      §  liter  milk;  40  Gm.  toast;  10  Gm.  butter        .      .     504.0 

Luncheon.     Oatmeal  soup;  15  Gm.  puro 90.0 

Noon  Vegetable  green  soup,  one  yolk  of  egg;  150  Gm. 

(Dinner).       roast  beef,  game,  fowl  or  fish,  finely  hacked; 

40  Gm.  toast;  100  Gm.  mashed  potatoes     .      .     667.4 

Afternoon.     \  liter  milk-cocoa,  one  yolk  of  egg;  30  Gm.  zwie- 
back          400.0 

Evening         Flour  milk  gruel,  viz.:  250  Gm.  milk,  20   Gm. 
(Supper).       tapioca,  oatmeal  or  mondamin,  15  Gm.  sugar; 

50  Gm.  toast 300.0 


1961.4 
(Zweig.) 


516 


TUMORS  OF  THE  STOMACH 


Morning. 

Forenoon. 
Noon. 


Afternoon.' 
Evening. 

10  P.M. 

With  Cocoa 
With  Kefir. 


150  Gm.  malt  legumi- 
nose  cocoa    . 

250  Gm.  kefir  .      .      . 

150  Gm.  mah  legumi- 
nose  soup 

100  Gm.  scraped  beef- 
steak      .... 

250  Gm.  malt  legumi- 
nose  cocoa    . 

100  Gm.  scraped  ham 

150  Gm.  tapioca  gruel 

200  Gm.  kefir  .      .      . 
30  Gm.  honey 
20  Gm.  cognac 


Intermediate.  50  Gm.  zwdeback 


Carbo- 

r'rotein. 

Fat. 

hydrates. 

Alcohol. 

6.0 

4.0 

13.5 

6.0 

4.5 

3.8 

1.0 

4.0 

20.0 

6.0 
25.0 
7.0 
6.0 
0.4 

6.6 


0.15 

6.0 

4.0 
8.0 
5.0 
4.5 


1.0 


87.0        37.15 
Total  combustion  value,  about  1250  calories. 


9.3 


13.5 

8.0 

3.8 

22.0 

35.0 


1.0 
14.0 


108.9         16.0 
(Wegele.) 


Protein. 

6  A.M.     500  Gm.  milk,  40  Gm.  toast     .  20.3 

8  A.M.     Oatmeal  soup  with  15  Gm.  meal 

solution,  or  soup  of  \  Timpe's 

soup  tablet  .  .  5.5 

10  A.M.     Cream  mixture:  125  Gm.  cream, 

6  Gm.   milk  sugar;  40  Gm. 

toast 7.8 

12  M.         (a)  soup  with  1  yolk  of  egg       .  4.0 

(6)  140  Gm.  roast  beef,  game, 
fowl,  boiled  hacked  beef  or 
fish 42,8 

(c)  40  Gm.  toast        ....  3.3 

(d)  25  Gm.  cinnamon-soda  cake 
biscuits 2.0 

(e)  1  small  cup  black  coffee 

4  P.M.       250    Cc.    milk-water   cocoa,    3 

zwieback  (30  Gm.)      ...  9.2 

7  P.M.  {a)  Leguminous  soup  with  15 
Gm.  meat  solution  or  soup 
of  \  Timpe's  soup  tablet  7.6 

(6)  Rice-flour  gruel  ....  18.3 

120.8 

Total  combustion  value,  about  2524  calories. 


Carbo- 
Fat.  hydrates. 

18.4  55.8 


1.0 


11.3 


1.0 
14.1 


14.2 


12.9 

41.5 

9.2 

7.7 

10.4 

0.4 

30.8 

1.5 

14.0 

38.3 


12.6 
98.1 


80.2         313.0 
(Biedert.) 


CARCINOMA  517 

Carbo- 
Protein.  Fat.  hydrates. 

6  a.m.     250  Cc.  milk,  30  Gm.  toast       .  11.0  9.3  35.6 
8  a.m.     2  eggs  with  20  Gm.  toast     .      .           13.7         10.2  15.4 

10  a.m.     125  Cc.  cream,  20  Gm.  zwieback  6.9         14.0  18.8 

12  m.         (a)  140  Gm.  roast  beef,  game, 
or  fowl,  boiled  choj)ped  beef 

or  fish 42. S         10.4 

(6)  40  Gm.  toast       ....  3.3  0.4  30.8 

(c)  25  Gm.  soda-cinnamon  bun 

or  biscuits 2.0  l.o  14.0 

4  p.m.     250   Cc.    milk-cocoa,    30    Gm. 

zwieback  with  fruit  jelly      .  13.5         15.8  44.6 

7  p..\i.     Rice  pudding,  20  Gm.  zwieback, 

or   25    Gm.    baked   foods   as 

above 14. S         10.8  78.7 

10  p.m.     2.50  Cc.  milk,  20  Gm.  zwieback  10.9         10.5  26.3 

118.9         82.9         264.2 
Total  combustion  value,  2341  calories. 

(Biedert  and  Langermann.) 

7  A.M.    Flour  soup,  boiled  with  cream  and  butter.    Biscuits  with  butter. 

9.15      Tea  with  cream,  butter  roll,  scraped  lean  ham,  or  one  soft  egg. 

12  M.       One  plateful  rice  soup,  spinach,  carrot  or  bean  puree,  scraped 

chicken,  boiled  fish,  sweet  preserves. 
3  P.M.    Cocoa  boiled  with  cream.     Butter  biscuits. 
5 .  30      Flour  soup  or  flour  gruel  with  much  butter. 
7.15       Tea  with  cream,  scraped  ham,  butter  roll,  milk  ad  libitum. 

(Cohnheim.) 

Treatment  by  Lavage. — Washing  out  the  stomach  in  gastric 
carcinoma  is  an  important  auxihary  to  the  dietetic  treat- 
ment. Lavage  is  indicated  when  the  motor  function  of  the 
stomach  is  disturbed.  It  is  especially  indicated  in  pyloric 
stenosis  with  motor  insufficiency  of  the  second  degree,  as 
well  as  in  motor  insufficiency  of  the  first  degree.  In  the 
latter  condition  it  is  not  necessary  to  wash  the  stomach 
every  day.  In  motor  insufficiency  of  the  second  degree, 
however,  daily  lavage  should  be  performed,  preferably  at 
night  before  supper.  This  daily  lavage  has  the  happy  effect 
of  relieving  patients  of  many  of  their  distressing  symptoms; 
vomiting  ceases,  the  pains  decrease  in  severity,  the  appetite 
improves,  and  there  is  a  marked  improvement  in  the  nutri- 
tion.    Patients  take  on  new  hope,  which  is  an  important 


518  TUMORS  OF  THE  STOMACH 

matter  in  the  treatment  of  gastric  cancer.  Lavage,  however, 
will  not  arrest  the  cachexia  resulting  from  cancer;  yet,  in 
spite  of  the  graduallj^  progressive  weakness,  patients  remain 
free  from  many  subjective  symptoms  which  would  other- 
wise render  their  existence  a  greater  burden.  Lavage  should 
be  followed  up  by  irrigation  with  antifermentative  solu- 
tions, especially  when  there  is  marked  formation  of  gas  as 
shown  by  eructations.  The  lavage  process  should  not  be 
prolonged,  since  it  requires  more  or  less  effort  on  the 
part  of  the  patient.  Boas  recommends  as  a  substitute  for 
lavage  a  partial  expression  of  the  stomach  contents.  This 
should  be  done  in  the  evening  and  should  take  the  place 
of  regular  lavage. 

Physical  Treatment. — This  consists  of  local  applications  in 
the  form  of  moist  trunk  packings,  or  hot  moist  or  dry  stupes 
apphed  in  the  gastric  region  to  counteract  the  feehng  of 
gastric  pressure,  pains,  and  nausea  (see  p.  150).  ]\Iassage 
and  electricity  are  not  indicated  in  gastric  cancer. 

Mineral  Water  Cure. — ^Mineral  waters  have  not  been  found 
satisfactory  agents  in  the  treatment  of  gastric  carcinoma. 
Sojourn  at  the  so-called  health  resorts  has  not  been  attended 
by  any  marked  improvement  in  the  condition  of  the  patient. 

Medicinal  Treatment. — The  treatment  of  carcinoma  of  the 
stomach  hj  drugs  consists  almost  entireh'  in  the  relief  of 
distressing  sjTnptoms.  Condurango  bark  has  been  employed 
most  frequently  as  a  medicinal  agent  for  the  stimulation  of 
the  appetite.  It  was  believed  at  one  time  to  possess  certain 
curative  virtues  in  cancer.  But  while  no  drug  has  been  found 
to  exert  any  influence  by  way  of  shortening  or  curing  the 
disease,  condurango  is  still  worthy  of  trial  as  a  stomachic. 
It  has  an  ameliorating  effect  upon  nausea,  vomiting,  and 
pain,  and  on  this  account  is  to  be  preferred  to  the  other 
bitter  tonics.    It  is  administered  in  the  form  of  a  decoction. 

Gm.  or  Cc. 

I^ — Corticis  condurango 15.0         Sss 

Macerate  for  twelve  hours  with  distilled 

water 360.0         5xij 

Sig. — Three  times  a  day,  tablespoonful  before  meals. 


CARCINOMA  519 

Gm.  or  Cc. 

I^ — CorticLs  c'ondurungo 15.0  5ss 

Macerate  for  twelve  hours  with  distilled 

water 300.0  5x 

Strain  and  reduce  to      .      .      .■    .      .      .       180.0  5vj 

Add  syrup  of  orange  peel 15.0  5ss 

Sig. — One  tablespoonful  three  times  a  day.     (Zweig.) 

Condurango  bark  should  be  administered  regularly  over 
a  prolonged  period  of  time  in  order  that  the  patient  may 
secure  the  full  benefit  of  it.  It  is  apt  to  fail  when  anorexia 
is  pronounced.  In  place  of  the  decoction,  the  fiuidextract 
may  be  prescribed,  one  teaspoonful  in  a  wineglass  of  water 
a  half -hour  before  meals.  The  wine  of  condurango  is  also 
deserving  of  consideration. 

In  addition  to  condurango  bark,  the  cinchona  prepara- 
tions, tincture  of  gentian,  and  orexin  may  be  prescribed. 

In  subacidity  and  anacidity,  pepsin  and  hydrochloric  acid 
may  be  employed  for  the  purpose  of  increasing  proteolysis. 
The  hydrochloric-acid-pepsin  treatment,  however,  occupies 
a  much  less  important  position  in  the  treatment  of  achylia 
complicating  carcinoma  than  in  achylia  and  subacidity  of 
benign  origin. 

Condurango  is  also  prescribed  with  hydrochloric  acid, 
antiseptics,  and  tonics: 

Gm.  or  Cc. 

I^ — Corticis  condurango 15  to  20 . 0 

Macerate  for  twelve  hours  with  water 

Digest  at  mild  heat  and  strain,  obtaining 

Add  hydrochloric  acid 

Sig. — One  tablespoonful  before  meals.    (Riegel.) 


I^ — Decoctionis  corticis  condurango  . 

Acidi  hydrochlorici 

Syrupi q.  s.  ad 

Misce. 

Sig. — One  tablespoonful  three  times  a  day.    (Zweig.) 


0  20.0 

3iv-v 

300.0 

5x 

180.0 

§vj 

1.5 

TTlxxiv 

Gm.  or 

Cc. 

180.0 

5vj 

0.5 

TTlviij 

200.0 

5vij 

520  TUMORS  OF  THE  STOMACH 

Gm.  or  Cc. 

I^ — Corticis  condurango 20.0  3v 

Macerate  for  twelve  hours  with  water     .  300 .0  5  x 

Digest  at  mild  heat  and  strain,  obtaining  250 . 0  5  viij 

Add: 

ResorcinoHs 4.0  oj 

Acidi  hydrochlorici  dikiti 3.0  TTlxlv 

Syrupi  zingiberis 300 .0  ox 

Misce. 

Sig. — One  tablespoonful  three  times  a  day,  before  meals.     (Kuttner.) 

Gm.  or  Cc. 

I^ — Resorcinolis 1.0         gr.  xv 

Tincturse  nucis  vomicae 2.0         TTlxxx 

Vini  condurango 140.0         ov 

Misce. 

Sig. — Tablespoonful  three  or  four  times  daily,  before  meals.     (Roderi.) 

As  anodynes,  tincture  of  valerian  in  drop  doses,  or  spirits 
of  ether,  is  indicated.  When,  however,  the  pains  are  severe, 
orthoform  or  anesthesin  should  be  employed.  Pain  is  occa- 
sionally so  severe  as  to  require  the  administration  of  some 
narcotic.  Of  narcotic  drugs,  codeine  or  extract  of  bella- 
donna may  be  administered  in  the  form  of  rectal  supposi- 
tories as  well  as  by  mouth.  In  sleeplessness  resulting  from 
pain,  Wegele  recommends  the  administration  of  chloral 
hydrate  with  morphine  as  follows: 

Gm.  or  Cc. 

I^— ChloraU  hydrati 15.0          oSS 

Morphinse  sulphatis 0.15        gr.  ii§ 

Aquae  destillatae 120.0          giv 

Syrupi  aurantii 15. 0         oss 

Misce. 

Sig. — Tablespoonful  in  a  wineglass  of  water. 

The  pain  accompanying  gastric  carcinoma  is  met  by  the 
administration  of  opiates.  Morphine  should  be  reserved, 
however,  until  the  final  stages  of  the  disease. 

Cocaine  or  3  to  5  minims  of  chloroform  on  small  pieces 
of  ice  may  be  given  for  the  vomiting.  Robin  gives  4  or  5 
drops  of  the  following  mixture  before  each  attack: 


CARCINOMA  521 

Gm.  or  Cc. 

^ — Picrotoxini 0.05  gr.  j 

Alcoholis,  q.  s. 

Morphinaj  hydrochloridi O.Oo  gr.  j 

Atropinae  sulphatis 0.01  gr.  J 

Extracti  crgotae 0.01  gr.  ^, 

Aquaj  destillatae 12.00  3iij 

Misce. 


Boas  recommends  oil  of  chloroform  for  the  relief  of  vomiting 
accompanying  gastric  carcinoma,  in  the  following  formula: 

Gm.  or  Cc. 

I^ — Olei  amygdalae  express!, 

Chloroformi aa       10.0  3iiss 

Misce. 

Sig. — Ten  to  fifteen  drops  to  be  given  as  required. 


For  distress  caused  by  excessive  gaseous  fermentation, 
antiseptic  drugs  occasionally  give  good  results: 

Gm.  or  Cc. 

I^ — Resorcinolis, 

Tincturje  opii aa  2.0  3  ss 

Aquae 180.0         §vj 

Syrupi q.  s.  ad      200.0         ovij 

Misce. 

Sig. — One  tablespoonful  every  two  hours. 


When  the  vomiting  is  obstinate  it  will  be  necessary  to 
resort  to  narcotics,  which  may  be  administered  either  hypo- 
dermically  or  by  rectum. 

The  medicinal  treatment  of  gastric  hemorrhage  resulting 
from  carcinoma  is  that  of  other  kinds  of  hemorrhage  from 
the  stomach. 

To  counteract  diarrhea  Boas  recommends  this  prescrip- 
tion: 

Gm.  or  Cc. 

I^ — Fluidextracti  condurango, 

Fluidextracti  calumbae aa       20 . 0  5  v 

Misce. 

Sig. — A  teaspoonful  three  times  a  day  in  a  wineglass  of  water. 


522  TUMORS  OF  THE  STOMACH 

Since  these  gastrogeiiic  diarrheas  result  from  the  presence 
of  decomposed  gastric  contents  in  the  intestinal  tract,  anti- 
septics such  as  resorcinol  or  bismuth  salicylate  are  indicated. 
Yet  the  regulation  of  diet  and  the  performance  of  gastric 
lavage  are  usually  more  effective  than  the  drug  treatment 
in  counteracting  this  condition. 

When  constipation  is  present,  high  rectal  enemata  of 
large  quantities  of  water  are  productive  of  good  results. 
OUve  oil  and  glycerin  enemata  and  glycerin  suppositories 
should  also  be  tried. 

Heart  failure  is  to  be  met  by  such  excitants  as  digitahs 
and  caffeine. 

Attempts  have  been  made  to  directly  influence  the  growth 
of  carcinoma  of  the  stomach  by  means  of  drugs.  Boas 
reports  temporary  diminution  in  the  size  of  the  tumors 
after  the  use  of  sodium  iodide  in  daily  doses  of  2  to  3  Gm. 
(30  to  45  grains).  Temporary  relief  has  been  reported  from 
the  use  of  arsenic  in  the  form  of  Fowler's  solution,  adminis- 
tered over  a  long  space  of  time  in  gradually  increasing  doses. 
Sodium  cacodylate  may  be  given  in  larger  doses,  0.1  to  0.5 
Gm.  (1^  to  7|  grains),  or  in  sterile  solution  hypodermically. 
A  few  clinicians  have  reported  a  temporary  diminution  in 
the  size  of  the  tumors,  as  well  as  improvement  in  the  general 
condition,  from  the  protracted  administration  of  methylene 
blue.  This  drug  ma}^  be  given  in  pill  form,  0.06  Gm.  (1 
grain)  three  times  a  day,  or  in  suppositories,  0.06  Gm. 
with  0.02  Gm.  {\  grain)  of  extract  of  belladonna  to  each 
suppository.  Of  other  drugs  which  have  been  used  to  inhibit 
the  growth  of  the  neoplasm,  or  if  possible  diminish  its  size, 
chlorinated  soda  and  chelidonium  might  be  mentioned. 

Although  a  few  favorable  results  have  been  reported  from 
the  use  of  atoxyl  in  the  form  of  a  1-per-cent.  soap  cream, 
applied  endermically,  the  value  of  this  treatment  has  not 
been  established.  The  atoxyl  was  rubbed  into  the  skin  at 
first  six  times  a  day  and  later  twice  a  day.  The  rubbing 
was  continued  until  a  distinct  feeling  of  warmth  was 
experienced  by  the  patient.  Lecithin  was  administered  at 
the  same  time.      The    treatment   was    soon    followed   by 


CARCINOMA  52'A 

improvement  in  botli  subjective  and  objective  symptoms. 
The  tumor  began  to  disappear,  and  the  patient's  appetite 
improved. 

Adanikiewicz  has  employed  a  serum  called  cancorin, 
which  is  of  doubtful  value.  The  cancer-cure  serum  of 
Doyen  is  prol^ably  also  without  much  merit.  Good  results 
in  the  way  of  producing  a  shrinking  and  softening  of  the 
cancerous  masses  have  been  reported  from  the  use  of  can- 
crodin,  prepared  b}^  Schmidt  of  Cologne. 

Success  in  the  treatment  of  cancer  has  been  reported  from 
the  use  of  the  Roentgen  rays;  tumors  of  the  stomach  have 
in  some  instances  wholly  disappeared.  Einhorn  has  used 
radium  in  the  treatment  of  gastric  cancer  as  well  as  cancer 
of  the  esophagus.  The  radium  is  deposited  in  radium 
receptacles,  which  consist  of  hard  rubber  capsules,  the  parts 
of  which  are  connected  by  screw  threads.  The  capsule  is 
attached  to  a  silk  cord  about  75  centimeters  in  length,  and 
introduced  into  the  stomach  in  the  same  manner  as  the 
stomach  bucket.  It  is  retained  in  the  stomach  for  one  hour 
at  a  time.  According  to  Einhorn  the  results  of  the  radium 
treatment  have  been  satisfactory,  considering  that  the 
disease  has  not  heretofore  been  amenable  to  treatment. 
' '  In  the  methodical  application  of  radium  we  have  the  means 
to  influence  favorably  the  course  and  seat  of  the  disease 
and  to  retard  its  progress,  even  if  at  present  we  cannot 
entirely  remove  it.  This  mode  of  treatment  is  certainly 
destined  to  play  an  important  role  in  the  therapeutics  of 
cancer  of  the  esophagus,  and  deserves  to  be  tried  on  a  large 
scale  and  in  a  thorough  manner."     (Einhorn.) 

Von  Leyden  and  Bergell  have  ventured  to  treat  carcinoma 
of  the  stomach  along  biological  lines.  According  to  the 
theory  of  these  investigators,  in  healthy  individuals  certain 
substances  are  always  present  which  act  as  a  ferment  and 
inhibit  the  growth  of  malignant  tumors,  and  these  sub- 
stances are  lacking  or  deficient  in  cancer  patients.  Trypsin 
is  said  to  develop  the  peculiar  kind  of  immunity  afforded  by 
these  substances.  \on  Leyden  and  Bergell  have  endeavored 
to  counteract  the  patient's  poverty  in  ferments  by  the  use 


524  TUMORS  OF  THE  STOMACH 

of  a  proteolytic  enzyme  obtained  from  the  fresh  Uvers  of  ani- 
mals; trypsin  itself  has  been  employed.  Up  to  the  present 
time,  however,  no  marked  results  have  justified  either  this 
theory  of  immunity  or  this  line  of  treatment. 

Treatment  of  Carcinoma  of  the  Cardia. — The  diet  should  be 
carefully  regulated,  to  minimize  the  difficulties  of  degluti- 
tion which  accompany  stenosis  of  the  cardia,  when  the  seat 
of  the  carcinoma  is  the  cardiac  entrance  to  the  stomach. 
It  should  be  such  as  to  produce  as  little  irritation  as  possible 
at  the  cardiac  orifice.  The  use  of  bland  food,  soft  in  con- 
sistency, will,  to  a  large  extent,  ward  off  the  tendency  to 
disintegration  of  the  tumor-like  mass,  and  prevent  hemor- 
rhages and  rapidity  of  growth.  Meats  should  be  given  in 
finely  divided  form,  and  potatoes,  vegetables,  and  preserved 
fruit  as  puree  only.  Flour-and-milk  soups,  eggs,  milk, 
cream,  and  artificially  prepared  foods  may  be  prescribed 
so  long  as  they  can  be  swallowed  with  ease.  The  mainte- 
nance of  the  general  nutrition  will  not  be  a  difficult  matter, 
since  the  articles  mentioned  may  be  taken  in  large  quanti- 
ties. As  the  cardiac  stenosis  becomes  more  marked,  the 
question  of  adequately  nourishing  the  patient  assumes  a 
graver  aspect.  The  diet  must  eventually  be  entirely  liquid. 
Cohnheim  proposes  the  following  liquid  regimen: 

8  A.M.     Tea  with  125  Gm.  cream. 

9  A.M.     Milk,  250  Gm. 

11  A.M.     Flour  soup  with  125  Gm.  cream  and  butter. 
1  P.M.     Bouillon  with  one  tablespoonful  of  flour,  one  to  two  yolks  of 

egg,  and  butter. 
4  P.M.     Tea  with  125  Gm.  cream. 
6  P.M.     Flour  soup  or  milk. 
8  P..M.     Bouillon  with  ground  rice  or  flour  and  butter. 

Patients  may  partake  of  the  following  ad  lihitum:  Wine, 
beer,  milk,  buttermilk,  kefir,  fruit  juices,  mineral  waters, 
vanilla  ice  cream,  and  artificial  food  preparations.  They  can 
be  sustained  for  a  long  time  with  the  above  regimen,  pro- 
viding the  painful  symptoms  are  not  such  as  to  prevent 
them  from  swallowing  the  liquid  nourishment.  When 
patients  are  unable  to  consume  even  a  liciuid  diet,  owing  to 


CARCINOMA  525 

difficulties  in  deglutition,  a  good  quality  of  olive  oil  should 
be  administered  in  generous  amount.  The  oil  has  the  effect 
of  lubricating  the  stenosed  cardia  so  that  food  will  pass 
into  the  stomach  more  easily.  Sometimes  the  inability  to 
swallow  arises  more  from  the  inflamed  condition  of  the 
cardia  than  from  the  degree  of  stenosis;  the  oil  in  such  cases 
serves  the  ]:)urpose  of  a  protective  layer  upon  the  neoplasm, 
rendering  it  less  sensitive  and  thereby  preventing  spastic 
contraction  of  the  cardiac  orifice.  Olive  oil,  moreover, 
has  a  high  nutritive  value.  At  least  half  a  wineglass  of  the 
oil  should  be  taken  morning,  noon,  and  night,  half  an  hour 
before  the  ingestion  of  other  food.  Almond  milk  is  the  most 
efficient  substitute  for  olive  oil,  should  the  latter  become 
distasteful  to  the  patient.  When  the  stricture  becomes  so 
marked  as  to  preclude  the  passage  of  even  liquids,  aided  in 
their  passage  by  the  oil,  then  whatever  is  partaken  of  by 
mouth  lodges  in  the  lower  portion  of  the  esophagus,  above 
the  constriction,  only  to  be  expelled  by  vomiting.  And  the 
inflammatory  irritation  and  ulceration  of  the  diseased  area 
will  frequently  cause  vomiting  or  retching  when  there  is  no 
accumulation  of  food  in  the  esophagus.  Rosenheim  recom- 
mends systematic  lavage  of  the  esophagus,  by  means  of 
the  ordinary  soft  stomach  tube  introduced  as  far  as  the 
stricture.  When  the  food  remnants  are  removed  the  lavage 
process  should  be  continued  with  small  quantities  of  warm 
water  until  all  mucus,  pus,  and  blood  are  washed  away. 
The  esophagus  may  be  rinsed  with  mild  antiseptic  solu- 
tions. After  the  rinsing  process,  30  to  60  Cc.  (5j-ij)  of 
olive  oil  should  be  injected  into  the  esophagus.  Esophageal 
lavage  should  be  performed  at  first  once  a  day,  and  later 
on  every  second  day.  Food  may  be  taken  one  hour  after 
the  lavage.  Patients,  as  a  rule,  are  very  much  relieved  by 
the  systematic  washing  and  lubrication;  the  irritability  of 
the  diseased  area  is  allayed,  and  frequently  deglutition  is 
facilitated. 

By  regularly  sounding  and  dilating  the  cardiac  stricture 
the  progressive  stenosis  may  be  inhibited  for  a  considerable 
length  of  time.     Some  clinicians,  however,  are  opposed  to 


526  TUMORS  OF  THE  STOMACH 

the  use  of  the  sound,  fearing  mechanical  irritation  that 
may  stimulate  the  carcinoma  to  further  growth.  It  is  true 
that  damage  may  result  from  the  injudicious  use  of  the 
sound.  Mechanical  dilatation  of  the  carcinomatous  stric- 
ture should  not  be  considered  so  long  as  the  patient  is  able 
to  swallow  a  sufficient  quantity  of  liquid  and  semisolid 
nourishment  to  maintain  nutrition.  When,  however,  this 
cannot  be  done,  the  physician  may  succeed  in  so  far  dilating 
the  stricture  as  to  enable  the  patient  to  swallow^  with  com- 
parative ease.  For  the  purpose  of  dilatation,  elastic  bougies 
of  a  diameter  corresponding  to  the  lumen  of  the  stricture 
should  be  employed.  Sounds  increasing  in  size  should  be 
used  as  the  stricture  yields  to  the  dilating  process.  The 
sounds  need  be  introduced  but  once  a  day,  and  should  be 
kept  in  position  from  fifteen  to  thirty  minutes.  Should 
symptoms  of  irritation  arise,  the  dilatation  must  be  inter- 
mitted for  several  days.  The  stomach  tube  may  be  utilized 
for  the  introduction  of  nourishment  into  the  stomach. 
Any  food  introduced  through  the  tube  should  be  of  a  con- 
centrated nature,  representing  the  highest  percentage  of 
calories  per  unit  of  volume.  The  food  may  consist  of  a 
pint  of  milk,  with  somatose  or  other  protein  preparation, 
two  to  three  eggs,  three  ounces  of  sugar,  malt  extract  or 
dextrinized  milk,  wine  and  salt.  When  the  feeding  by  mouth 
(or  tube)  is  not  sufficient,  rectal  alimentation  may  be  em- 
ployed for  a  few  days.  Analgesic  and  antispasmodic  drugs 
are  sometimes  prescribed,  to  diminish  the  difficulties  of  swal- 
lowing. Morphine  or  cocaine  may  be  swallowed  as  drops  or 
tablets ;  the  following  is  very  useful : 

Gm.  or  Cc. 

I^ — MorphinPD  hj-drochloridi, 

Cocainae  hydrochloridi aa     0 .  0025         gr.  jV 

Antipyrinaj 0.1  gr.  iss 

Sacchari 0.3  gr.  v 

Misce  et  ft.  tab.  no.  i. 

Sig. — One  tablet  before  partaking  of  food. 

Other   useful    prescriptions    for    internal    medication    in 
gastric  cancer  are: 


SARCOMA  527 

Clni.  or  C'r. 

I^ — Tincturse  bclladonnic 4  to  10.0  oj-iiss 

Emulsionis  amygdalae    .      .       q.  s.  ad  200.0  3viij 

Misce. 
Sig. — One  tablespoonful  to  be  taken  before  meals.     (Cohnheim.) 

Gm.  or  Cc. 

^ — Codeina)  phosphatis 0 . 5  to  1 . 0  gr.  viiss-xv 

Aqua)  amygdala;  amarse      ....  15.0  5ss 

Misce. 
Sig. — Fifteen  to  twenty  drops  three  times  a  day.    (Cohnheim.) 

Solutions  of  5-per-cent.  cocaine  or  3-per-cent.  eucaine  may 
be  injected  directly  as  far  as  the  cardiac  orifice  by  means 
of  a  small  stomach  tube  or  long  Nelaton  catheter  attached 
to  an  ordinary  piston  syringe. 


SARCOMA 

Etiology. — While  carcinoma  is  a  comparatively  frequent 
affection  of  the  stomach,  primary  gastric  sarcoma  is  rare. 
Hosch,  in  13,387  autopsies,  found  but  six  primary  gastric 
sarcomata,  and  Tilger  in  3500  autopsies  found  only  one. 
Although  an  admittedly  rare  condition,  recent  research  has 
shown  that  many  cases  diagnosticated  as  carcinoma  have 
upon  reinvestigation  proved  to  be  of  the  sarcomatous  type. 
Perry  and  Shaw,  on  examining  50  cases  of  so-called  carci- 
noma ventriculi  obtained  from  the  Guy's  Hospital  Museum, 
London,  discovered  that  four  of  the  specimens  were  round- 
celled  sarcoma.  According  to  Fenwick,  5  to  8  per  cent,  of 
all  primary  neoplasms  of  the  stomach  are  to  be  classed  as 
sarcomata. 

Of  the  etiology  of  gastric  sarcoma  very  little  is  known. 
Heredity  and  trauma  have  been  considered  as  positive 
predisposing  influences.  Ulcer  of  the  stomach  is  but  rarely 
the  starting  point  of  sarcoma.  Sex  seems  to  have  little  or 
no  influence  as  a  determining  factor.  The  majority  of  cases 
are  noted  between  the  ages  of  forty  and  fifty  years. 

According  to  Virchow,^  sarcoma  originates  in  the  mucous 

1  Geschwiilste,  ii,  p.  3.52. 


528  TUMORS  OF   THE  STOMACH 

membrane.  The  generally  accepted  view  is  that  it  originates 
in  the  submucous  or  mesoblastic  tissue. 

Pathology. — Sarcoma  is  a  neoplasm  consisting  of  small  cells 
of  an  adenoid  or  embryonic  type,  without  epithelial  appear- 
ance and  in  manj^  cases  without  stroma.  We  speak  of 
round-  or  spindle-celled  sarcoma,  according  to  the  character 
of  the  cell.  Primary  gastric  sarcoma  occurs  in  two  forms — 
infiltrated  and  circumscribed.  Round-celled  sarcomata  de- 
velop from  the  trabecular  tissue  of  the  gastric  submucosa; 
lymphosarcomata  from  the  lymphatic  nodules  of  the  sub- 
serous coat.  The  usual  location  or  starting  point  of  lympho- 
sarcomata is  the  pylorus;  this  variety  of  neoplasm  often 
infiltrates  the  entire  wall  of  the  stomach,  but,  as  a  rule, 
avoids  the  gastric  orifices.  Next  in  frequency  is  the  myxo- 
sarcoma, having  its  starting  point  in  the  muscular  coat. 
Fibrosarcomata  and  myxosarcomata  are  yevy  rare.  INIyo- 
and  fibrosarcomata  represent  the  circumscribed  form  of 
sarcoma,  which  often  acquires  an  enormous  size,  with 
frequent  metastases;  especially  is  this  true  of  round-celled 
sarcomata  and  lymphosarcomata  which  invade  the  peri- 
toneal lymphatic  glands,  the  pleural  cavities,  the  kidneys, 
ovaries,  spleen,  liver,  and  lungs.  Metastases  in  the  skin 
are  very  rare. 

Many  cases  of  gastric  sarcoma  cannot  be  distinguished 
clinically  from  gastric  carcinoma;  especiallj'  is  this  true  of 
the  round-celled  type,  in  the  course  of  which  ulceration, 
softening  and  hemorrhage,  and  more  rarely  obstruction, 
may  occur,  with  occasional  perforation.  Sarcoma  is  apt 
to  occur  at  a  much  earlier  age  than  carcinoma.  William 
Legg^  reports  a  case  in  a  girl  of  seventeen;  and  a  case  of 
round-celled  sarcoma  of  the  stomach  in  a  child  four  years 
of  age  has  been  reported  by  Thursfield.  Softening,  hem- 
orrhage and  perforation  occur  but  rarely  in  gastric  sarcoma. 
Owing  to  the  fact  that  sarcoma  is  an  infiltrating  growth, 
there  is  usually  no  contraction  and  no  obstruction.  If 
obstruction  does  occur,  it  is  mechanical  rather  than  due  to 
a  constriction  of  the  growth. 

'  St.  Bartholomew's  Hospital  H('i)orts,  1874,  p.  234. 


SARCOMA  529 

Alaschke^  reports  two  cases  of  primary  sarcoma  of  the 
stomach.  In  the  first  case  the  tumor  was  not  detected 
until  the  autopsy;  it  was  so  small  that  during  the  life  of 
the  patient  it  did  not  lead  to  suspicion  of  serious  disease  of 
the  stomach;  it  was  not  of  the  diffuse  infiltrating  variety, 
but  was  sharply  circumscribed.  In  carcinoma  the  tumor 
is  never  sharply  circumscribed.  In  the  second  case  reported 
by  Maschke  the  tumor  was  very  large  and  had  probably 
developed  very  rapidly.  Symptoms  of  gastric  disease  had 
made  their  appearance  only  six  weeks  before  death;  they 
consisted  of  hematemesis,  bloody  stools, .  and  some  pain 
in  the  epigastrium.  These  symptoms  and  the  emaciation, 
anemia,  palpable  resistance  in  the  gastric  region,  and 
absence  of  free  hydrochloric  acid  in  the  gastric  contents, 
pointed  to  the  diagnosis  of  carcinoma.  The  clinical  symp- 
toms of  sarcoma  of  the  stomach  are  not  essentially  different 
from  those  of  carcinoma,  so  the  chnical  diagnosis  is  very 
difficult  and  often  impossible.  Sarcoma  in  the  pyloric 
region  causes  stenosis  much  less  frequently  than  does 
carcinoma.  The  prognosis  in  gastric  sarcoma  is  unfavor- 
able unless  early  excision  is  done. 

Symptoms. — The  clinical  course  of  gastric  sarcoma  is 
subject  to  great  variation.  In  some  cases  symptoms  have 
been  present  for  years,  while  in  others  the  first  dyspeptic 
symptoms  were  coincident  with  a  discovery  of  the  tumor. 
In  some  cases  where  the  tumor  was  readily  palpable  the 
subjective  symptoms  were  very  slight.  Cachexia,  as  a  rule, 
occurs  very  late  in  the  disease.  Owing  to  the  fact  that  gas- 
tric sarcoma  seldom  produces  stenosis,  emesis  is  apt  to  be 
absent  throughout  the  course  of  the  disease.  Pains  in  the 
region  of  the  stomach  appear  early  and  may  be  very  severe. 
Free  hydrochloric  acid  is  absent  in  the  majority  of  cases. 
Lactic  acid  is  often  found  when  hydrochloric  acid  is  absent. 
The  Boas-Oppler  bacilli  are  not  constantly  present  in  gastric 
sarcoma.  Marked  degrees  of  anemia  develop  during  the 
progress  of  the  disease.  Hemorrhages  occasionally  take 
place,  though  death  from  hemorrhage  is  exceedingly  rare. 

1  Berliner  klin.  Wochenschrift,  May  23,  1910. 
34 


530  TUMORS  OF  THE  STOMACH 

The  importance  of  an  early  differential  diagnosis  between 
carcinoma  and  sarcoma  of  the  stomach  cannot  be  over- 
estimated, since  the  timely  surgical  treatment  of  sarcoma  is 
frequently  followed  by  gratifying  results.  Of  26  cases  of 
sarcoma  in  which  resection  was  done,  11  were  reported 
successful.  Lymphosarcomata  appear  to  be  especially 
adapted  for  operative  intervention.  The  results  depend, 
of  course,  entirety  upon  the  time  of  operation. 

Diagnosis. — As  an  aid  to  the  differential  diagnosis  the  reader 
is  referred  to  the  following: 

Differential    Diagnosis  of  Gastric  Carcinoma  and  Gastric  Sarcoma 


Carcinoma. 

Sarcoma. 

1. 

Much  pain. 

Much  pain  early,  which  diminishes 
as  the  tumor  becomes  palpable. 
Sometines  no  pain  at  all. 

2. 

Involvement  of  the  orifices. 

Orifices  either  not  involved  or 
rarely  involved. 

.3. 

Stenosis  marked. 

Stenosis  seldom. 

4. 

Hemorrhage  early. 

Hemorrhage  late  in  the  course  of 
the  disease. 

5. 

Markedly  mahgnant. 

Less  malignant. 

6. 

Growth  rapid. 

Growth  comparatively  slow. 

7. 

Metastases  early. 

Metastases  late. 

8. 

Cachexia  earlv. 

Cachexia  late. 

Treatment. — The  treatment  of  gastric  sarcoma  is  essen- 
tially surgical.  When  for  any  reason  surgical  intervention 
would  be  injudicious  or  not  likely  to  be  followed  by  benefi- 
cial results,  the  palliative  treatment  is  that  already  described 
for  gastric  carcinoma. 

W.  B.  Coley,  of  New  York  City,  reports  remarkably  good 
results  from  the  hypodermic  injection  of  mixed  toxins  (the 
toxins  of  erj^sipelas  and  the  Bacillus  prodigiosus)  in  the 
treatment  of  inoperable  sarcoma. 

BENIGN   TXJMORS 

Benign  tumors  of  the  stomach  are  of  exceedingly  rare 
occurrence.  They  seldom  give  rise  to  any  symptoms  dur- 
ing life,  though  occasionally  ulceration  of  the  tumor,  hemor- 


HERNIA  EPIGASTRICA  531 

rhage,  or  even  obstruction  may  occur.  Such  growths 
are,  as  a  rule,  discovered  at  autopsy.  They  are  simple  or 
multiple,  sessile  or  pedunculated.  They  are  classified 
according  to  the  tissues  or  gastric  layers  from  which  they 
are  derived.  Among  tumors  derived  from  the  glandular 
structure,  or  gastric  mucosa,  are  mucous  polypi,  mucous 
papilloma,  and  adenoma;  these  terms  are  applied  to  tumors 
of  the  mucosa,  multiple,  of  small  size,  either  sessile  or  pedun- 
culated. These  tumors  may  present  the  appearance  of  small 
vegetations  or  mammillations ;  individually  they  are  seldom 
larger  than  a  small  bean.  They  are  commonly  found  near 
the  cardia,  rarely  in  the  region  of  the  pylorus. 

Tumors  derived  from  connective  tissue  are :  (a)  Lipomata, 
or  fatty  tumors  arising  from  the  submucosa  in  any  part  of 
the  gastric  walls.  (6)  Fibromata.  Some  of  the  older  writers 
described  these  as  probably  slow-growing  carcinomata  with 
much  fibroid  stroma.  To  this  class  belong  the  fibrous 
thickenings  of  the  pylorus  due  to  spasm  or  chronic  inflam- 
mation or  resulting  from  an  old  cicatrizing  ulcer.  True 
fibromata  are  villous  growths,  usually  covered  with  a  single 
layer  of  cylindrical  cells;  they  are  often  polypoid  and  pedunt 
culated.  (c)  Fibromyomata — benign  tumors  which  projec- 
into  the  stomach.  These  consist  of  unstriped  muscle  fibres 
in  fibrous  tissue,  with  the  mucous  membrane  covering 
intact.  They  develop  in  the  muscular  layer  of  the  stomach 
wall,  are  rarely  larger  than  a  pea,  and  produce  no  symptoms. 

Cysts  of  the  stomach  are  usually  formed  by  the  occlusion 
of  a  duct  of  a  gastric  gland;  they  may  attain  the  size  of  a 
small  walnut,  but  are  usually  very  small  and  multiple, 
having  the  appearance  of  groups  of  minute  vesicles. 


HERNIA  EPIGASTRICA 

Hernia  epigastrica  consists  of  a  rupture  occurring  at  some 
part  of  the  linea  alba  between  the  umbilicus  and  the  ensi- 
form  appendix.  It  belongs  to  the  class  of  preperitoneal 
lipomata,  is  made  up  of  omentum  and  fat,  and  varies  in 


532  TUMORS  OF  THE  STOMACH 

size  from  a  bean  to  an  egg.  The  region  must  be  carefully 
palpated  in  order  to  diagnosticate  epigastric  hernia;  with 
a  tumor  of  considerable  size,  there  may  be  felt  at  the  tips 
of  the  fingers  a  sensation  as  though  small  shot  were  hitting 
them  when  the  patient  coughs. 

Hernia  epigastrica  may  produce  symptoms  simulating 
those  of  almost  any  gastric  disease,  and  for  that  reason 
it  is  of  the  greatest  importance  that  an  accurate  diagnosis 
be  made.  The  condition  has  been  mistaken  for  gastric  ulcer, 
gastritis,  gastralgia,  carcinoma,  enteritis,  and  cholelithiasis. 

Ehrlich^  reports  success  in  the  treatment  of  four  cases  of 
small  epigastric  and  navel  hernia  by  the  use  of  fibrolysin. 
He  believes  these  hernise  cause  distress  by  the  tension  of  the 
formed  adhesions.  The  fibrolysin  softens  the  adhesions,  and 
the  rehef  is  quite  prompt.  Ehrlich  injected  the  fibrolysin 
deep  in  the  abdominal  muscles  near  the  hernia,  and  massaged 
the  parts  after  each  injection.  The  contents  of  one  ampoule 
of  fibrolysin,  2.3  Cc,  were  injected  at  intervals  of  one  to 
three  days.  The  pain  subsided  after  three  to  five  injections. 
He  usually  gave  ten  injections  in  all  (see  p.  414 1. 

One  case  of  mine,"  reported  in  1897,  had  been  previously 
treated  for  over  four  years  for  a  presumed  chronic  gastritis. 
There  were,  with  intervals  of  freedom  from  symptoms, 
recurring  attacks  of  nausea,  vomiting,  epigastric  pain,  and 
anorexia.  The  patient  lost  28  pounds  in  four  months  on 
account  of  his  persistent  inability  to  retain  food.  After  the 
removal  of  the  tumor,  which  was  not  known  to  the  patient 
as  hernia,  a  speedy  recovery  took  place.  The  patient  con- 
tinued well,  without  any  gastric  symptoms,  for  eighteen 
years.     The  treatment  of  epigastric  hernia  is  surgical. 

'  Fibrolysininjektionen  zur  Behandlung  von  Nabel  und  Epigastrischen 
Hemien,  Archiv  fur  Verdauungskrankheiten,  February,  1911,  p.  43. 

2  Charles  D.  Aaron,  Stomach  Disturbances  Caused  by  Hernia  of  the 
Linea  Alba  in  the  Epigastrium,  Medical  Record,  November  20,  1897. 


CO:\IPARATIVE  SCALES  OX  TPIE  METRir'  AND 
ORDIXARY  WEIGHTS  AND  :\IEASURES 


Gm.  or  Cc 

Fluid  Measure, 
Ounces. 

Minims. 

A pot he 
Ounces 

icaries'  Weight 
1.          Grains. 

1000 

= 

33 

+ 

390.6 

= 

32 

+ 

72.4 

500 

= 

16 

+ 

435.3 

= 

16 

+ 

36.2 

250 

= 

8 

+ 

217.7 

= 

8 

+ 

IS.l 

100 

= 

3 

+ 

1S3.1 

= 

3 

+ 

103.2 

50 

= 

1 

+ 

331.5 

= 

1 

+ 

291.6 

25 

= 

405.77 

= 

385.8 

10 

= 

162.31 

= 

154.3 

5 

= 

81.2 

= 

77.2 

1 

16.23 

15.4 

Fluid  Measure.  Metric. 

2  pints  =  946.358  Gm.  or  Cc. 

1  pint  =  473.179  Gm.  or  Cc. 
i  pint  =  236.590  Gm.  or  Cc. 

3  ounces  =  88.721  Gm.  or  Cc. 

2  ounces  =  59.147  Gm.  or  Cc. 
1  ounce  =  29.573  Gm.  or  Cc. 

60  minims  =  3.697  Gm.  or  Cc. 


INDEX 


A 


Aaron's    bandage    for    enteroptosis, 
247,  248 
corset  for  enteroptosis,  254 
Abdominal     region,     application     of 

heat  to,  150,  151 
Abscess,  subphrenic,  surgery  of,  209 
Achlorhydria  gastrica  hsemorrhagica, 
310 
iodine  reaction  in,  52 
nervous  dyspepsia  and,  310 
Achroodextrin  in  chronic  gastritis,  72 

conversion  of  starch  into,  19 
Achylia  gastrica,  368 

etiology  of,  368 
Ewald-Boas    test    breakfast, 

in  diagnosis  of,  73 
gastric  contents  in,  73 
hydrochloric  acid  in,  170 
hypermotiUty  in,  260 
pathology  of,  370 
symptoms  of,  371 
treatment  of,  371.     See  also 
Gastritis,    chronic,    treat- 
ment of. 
Acid  eructations,  prescription  for,  351 
gastritis,  chronic,  314.     See  also 
Hyperchlorhydria. 
Acid-albumin,  27 
Acidity,  normal,  in  motor  insufficiency 

of  first  degree,  diet  in,  397 
Acidol,  173 
Acidum  hydrochloricum,  172 

dilutum,  172 
Adenocarcinoma,  506 
Adhesions  in  carcinoma,  507 
Adhesive    bandage    for    enteroptosis, 

249 
Adler's  original  benzidin  test,  55 
Adrenalin  for  gastric  hemorrhage,  469 
Aerophagy,    270.      See    Eructations, 

nervous. 
Akoria,  291 

Albumoses  in  peptones,  107 
Alcohol,  99 

in  diet  in  enteroptosis,  236 
effect  of,  on  gastric  secretion,  99, 

100,  188 
gastric  neurasthenia  and,  100 


Alcohol  in  peptones,  109,  110 
Alcoholism,  gastritis  and, chronic  phleg- 
monous, 357,  363 
Aleuronat  flour,  112 
Alimentary  hypersecretion,  343 
Alimentation,     duodenal,     Einhorn's, 
in  gastric  ulcer,  437 

rectal,  in  motor  insufficiency  of 
second  degree,  404 
Alkahes,  administration  of,  178,  179 
time  for,  182 

amylolysis  and,  182 

distinction  of,  from  antacids,  180 

effect  of,  on  secretions,  179 

groups  of,  1S2 

indications  for,  181 

in  treatment  of  hyperchlorhydria, 
325 
Alkaline  carbonated  waters,  156 

chlorine  waters,  153 

earths,  salts  of,  in  treatment  of 
hyperchlorhydria,  325 

saline  waters,  156 
Alkaloids    in    treatment     of    hyper- 
chlorhydria, 324 
AUouez  mineral  water,  analysis  of,  162 
American  mineral  waters,  159 
Amyl  nitrite,  191 
Amylodextrin,    conversion    of    starch 

into,  19 
Amylolysis,  alkalies  and,  182 
Amylopsin,  29 
Anacid  gastritis,  366 
Anacidity   in   motor   insufficiency   of 

first  degree,  diet  in,  397 
Analgesics  in  gastric  hemorrhage,  473 

in  hyperchlorhydria,  324 
Anemia  in  carcinoma,  508 

gastralgia  due  to,  massage  in,  135 

motor  insufficiency  and,  66 

in  sarcoma,  529 
Anesthesin,  194 
Angina,     abdominal,     arteriosclerosis 

and,  487 
Animal  protein,  preparations  of,  106 
Anodynes  in  carcinoma,  520  . 

gastric,  193 
Anorexia  in  carcinoma,  507 

electricity  in  treatment  of,  140 

nervous,  291 


536 


INDEX 


Anorexia,  nervous,  diseases  associated 
with,  291 
stomachics  for,  292 
treatment  of,  291 
Antacids,  180 

distinction  of,  from  alkalies,  180 
Antilytic  serum,  treatment  of  gastric 

ulcer  with,  451 
Antiseptics,  gastric,  198 
Appendicitis    larvata,    nervous    dys- 
pepsia and,  297 
nervous  dyspepsia  and,  296,  309 
Arsenic  in  carcinoma,  522 
Arteriosclerosis,  487 

abdominal  angina  and,  487 

diagnosis  of,  490 

diet  in,  491 

etiology  of,  487 

gastric  hemorrhages  and,  487 

ulcer  and,  487 
heart  in,  490 
old  age  and,  487 
overeating  and,  488 
overwork  and,  488 
pathology  of,  488 
symptoms  of,  490 
syphilis  and,  488 
toxic  factors  and,  488 
treatment  of,  491 
iodides  in,  492 
medicinal,  491 
thyroid  extract  in,  493 
Trunecek's  serum  in,  494 
Artificial  Carlsbad  salt,  181 

waters,  98 
Aspiration     method     for     obtaining 

stomach  contents,  34 
Aspirator,  stomach,  35 
Atony,  gastric,  73,  74 

electricit}^   in   treatment 
140 
motor  insufficiency  of  first  degree 

and,  394 
primary  intestinal,  massage  in,  134 
simple,  lavage  in,  118 
Atoxyl  in  carcinoma,  522 
Atropine,  195,  196 

in  gastric  hemorrhage,  473 
in  hyperchlorhydria,  322 
Auerbach's     plexus,     movements     of 

stomach  and,  22 
Autolavage,  124 


B 


Bacillus  of  l)();is-()|)plcr,  carcinoma 
and,  (■)!),  76,  509 
bulgaiicus,  93,  94 
Bacterial  vaccines,  treatment  of  gas- 
tric ulcer  with,  452 
Bandages  for  cnteroptosis,  247 


of, 


Bardenheuer's  corset  for  cnteroptosis, 

253 
Baths,  half,  147 

effect  of,  147 
temperature  of,  147,  148 
mineral,  158 
oxygen,  149 

in  nerA'ous  dyspepsia,  149 
preparation  of,  149 
prolonged,  149 
sea,  158 
Bead  test,  Einhorn's,  59 

technique  of,  60 
Beans,  97 

Beef,  essence  of.  Brand's,  116 
tea,  116 

nutritive  value  of,  90 
"Belt    sign,"    Glenard's,    in    cntero- 
ptosis, 246,  247 
Benign  tumors,  530 
Benzidin  paper,  Einhorn's,  56 
test,  Adler's  original,  55 
for  occult  blood,  54,  55 
Schlessinger      and      Hoist's 
modification    of,    55 
Bertrich  waters,  154 
Bile,  effect  of  hydrochloric  acid  on,  170 

in  stomach,  31 
Bilirubin,  31 
Biliverdin,  31 
Bismuth,  183 

bisalicylate,  effect  of,  185 
bitannate,  effect  of,  185 
contraindications  for,  184 
in  erosions,  481 
in  gastric  hemorrhage,  471 

ulcer,  184,  443 
in  hyperchlorhydria,  320,  321 
indications  for,  184 
salicylate,  effect  of,  185 
salts  of,  principal,  183 

use  of,  in  Roentgenography, 
183 
subcarbonate,  186 
subnitrate,  efl'ects  of,  1S5 
Bitter  waters,  157 

contraindications   for,    157 
indications  for,  157 
Bitters,  ISO 

classes  of,  187 

Reichmann's    experiments    with, 

189 
vegetable,  effect  of,  ISS 
Biuret  reaction,  51 
Blood  in  gastric  contents,  32,  52 
erosion  and,  52 
gastric    carcinoma   and, 
52,  53 
ulcer  and,  52 
test  for,  Weber's  guaiac, 
53 
occult,  53 


INDEX 


537 


Blood,  occult,  duodenal  ulcer  and,  54 
gastric  carcinoma  and,  53 

ulcer  and,  53 
tests  for,  54 

benzidin,  54 
phenolphthalein,  56,  57 
serum,  hemolytic  action  of,  diaj:;- 
nosis  of  carcinoma  from,  65 
Blue  Lick  water,  analysis  of,  162 
Boas'  diet  for  chronic  gastritis,  376, 
387 
for  enteroptosis,  242 
electrode,  140,  141 
food  cure  in  enteroptosis,  237 
nutrient  enema,  407 
test  breakfast,  33 

cancer  and,  33 
lactic  acid  and,  33 
Boas-Oppler  bacillus,  carcinoma  and, 
69,  76,  509 
pyloiic  stenosis  and,  74 
sarcoma  and,  529 
Bouillon,  Maggi's,  116 
Bovril,  116 

Brandenburg's  nutrient  enema,  408 
Brand's  essence  of  beef,  116 
Bread,  95 

brown,  95 
graham,  95 
rye,  95 
value  of,  95 
white,  95,  96 
Bright's  disease,  lavage  in,  120 
Bromides,  192 

Bronchitis,  contraindication   for   lav- 
age, 120 
Brown  bread,  95 
Bucket,  stomach,  35,  36 
Bulgarian  bacillus,  93,  94 
Bulimia,  289 

diseases  associated  with,  289 
electricity  in  treatment  of,  140 
motor  insufficiency  and,  67 
symptoms  of,  290 
treatment  of,  290 
Butter,  heat  value  of,  79 
Buttermilk,  92 


Cachexia  in  carcinoma,  508 

contraindication  for  lavage,  120 
in  sarcoma,  529 

Calorie,  definition  of,  79 

Cancer.    *SVe  Carcinoma. 

Cancorin  in  carcinoma,  523 

Cancrodin  in  carcinoma,  523 

Cannabis  indica,  192 

Canned  meat,  88 

Capitan's  nutrient   enema  in   gastric 
ulcer,  451 


Carbohydrates,  action  of  stomach  on, 
21 
in  chronic  gastrorrhca,  338 
in  diet  in  enteroptosis,  235 
digestion  of,  in  stomach,  52 
food  preparations  of,  114 
in  treatment  of  hyperchlorhydria, 
315 
Carbolic  acid,  197 
Carbonated  waters,  alkaline,  156 
Carcinoma,  503 
age  and,  504 
anemia  in,  508 
anodynes  in,  520 
anorexia  in,  507 
appetite  in,  507 
arsenic  in,  522 
atoxyl  in,  522 
blood    in    gastric    contents    and, 

52,  53 
Boas'  test  breakfast  and,  33 
Boas-Oppler  bacillus  and,  69,  76, 

509 
cachectic  appearance  in,  508 
cancorin  in,  523 
cancrodin  in,  523 
of  cardia,  diet  in,  524 

lavage  in,  525 

stenosis  and,  525 

stricture  and,  525 

treatment  of,  524 
colloid,  506 
complications  of,  506 

adhesions,  507 

perforation,  507 

rupture,  507 
condurango  bark  in,  518,  519 
contraindication  for   massage  of 

stomach,  134 
diagnosis  of,  75,  508 

early,  216 

from  gastric  ulcer,  426 

by  hemolytic  action  of  blood 
sei'um,  65 

from  motor  insufficiency  of 
second  degree,  403 

from  perigastritis,  484 

from  sarcoma,  530 
diet  in,  512,  513,  515,  516 
enemata  in,  nutrient,  515 
etiology  of,  503 
fats  in,  514 
fibrous,  506 
forms  of,  505 
gastrectomy  in,  510 
gastroenterostomy  in,  219,  511 
gastrogenic  diarrhea  in,  522 
gelatinous,  506 
heredity  and,  504 
hydrochloric  acid  in,  75,  217 
incidence  of,  503 
ischiochymia  and,  511 


538 


INDEX 


Carcinoma,  lactic  acid  in,  47,  76,  217, 
509 
laparotomy  in,  explorator3',  217, 

218,  509 
location  of,  505 
h'sins  in,  65 
malignancy  of,  505 
medullar^',  506 
metastases  of,  505,  509,  511 
narcotics  in,  521 
nausea  in,  507 
Xeubauer  and  Fisher's  test  for, 

63,  64 
occult  blood  and,  53 
pain  in,  507 
pathology  of,  504 
pepsin  in,  217 
pepsinogen  in,  24 
pylorectomy  in,  510 
rest  in,  512 
Roentgen  raj's  in,  523 
Salomon's  test  for,  63 
scirrhous,  506 
sex  and,  503 
simple,  506 
skin  reaction  in,  65 
stomach  contents  in,  509 
surgery  of,  215 
symptoms  of,  507 
treatment  of,  510 
internal,  512 
by  lavage,  516 
medicinal,  518 
mineral  water,  518 
physical,  518 
surgical,  510 

contraindications    for, 

511,  512 
indications  for,  510,  511, 
512 
trypsin  in,  523 
vomiting  in ,  507 
weakness  in,  507 
Cardia,  carcinoma  of,  treatment  of, 

524 
Cardialgia,  282.    See  also  Gastralgia. 
Cardiospasm,  262 
acute,  262 
diagnosis  of,  263 
etiology  of,  262 
oil  cure  for,  264 
prognosis  of,  263 
second   sound   of  deglutition   in, 

263 
symptoms  of,  262 
treatment  of,  263 

dilator  in,  Einhorn's,  266 

Myor's,  265,  266 

Plummer's,  206 

Sippy's,  264,  265 

electrotherapy  in,  267 

mechanical,  264 


Cardiospasm,  treatment  of,  sounds  for, 

266 
Carigen,  107 
Carlsbad  salt,  artificial,  181 

in  treatment  of  hvperchlor- 
hydria,  326,  327"^ 
waters,  154 

contraindications  for,  154 
indications  for,  154 
'  Casein,  curdling  of,  by  rennin,  27 
in  milk,  precipitation  of,  92 
Cataplasms,  150 

hot,  151 
Catarrh,   gastric,    chronic,   362.     See 
also  Gastritis,  chronic, 
of  stomach,  infectious,  353.    See 
also  Gastritis,  acute,  infectious. 
Champion  water,  analysis  of,  163 
Chase's  tube  for  stomach  douche,  131, 

132 
Cheese,  94 

Chemical  examination  of  stomach  con- 
tents, 39 
Chloral  hvdrate,  192 
Chloroform,  193 

for  gastric  hemorrhage,  473 
Chlorosis,    motor    insufficiencv    and, 

66 
Chocolate,  102 

Mering's  "Kraft,"  116 
CholeUthiasis,  nervous  dyspepsia  and, 

297 
Cirrhosis  ventricuh,  364 
Climatic  cures,  158 
Cocaine  hydrochloride,  193 
Cocoa,  102 
Cod-liver  oil,  115 
Coffee,  101 

Cold  pack,  entire,  148 
Coley's  treatment  for  sarcoma,  530 
Colloid  carcinoma,  506 
Colopto.sis,  220 
Compresses,  150 
Condiment,  Maggi's,  116 
Condurango  bark,  189 

in  carcinoma,  518,  519 
Congo  red  test  for  free  hydrochloric 

acid,  40 
Congress  water,  analj-sis  of,  165 
Constipation,     chronic,     massage    of 

stomach  in,  138 
Convulsions  from  overfeeding,  lavage 

in,  119 
Corsets  for  enteroptosis,  253 
Cramer's  diet  list,  102,  103 
Cream  conserve,  I^offlund's,  116 
Credo's  method  of  nia.'s.saKe,  135 
Crockett  arsenic-lit liia  water,  analysis 

of,  159 
Cykloforni,  195 
Cynorexia,  289.    See  also  Bulimia. 


INDEX 


539 


Uauk  meat.  S7  . 

Deep     Rock     water,     analysis     ot, 

160 
Deutero-albuinose,  027 
Dextrinated  flours,  114 
Dextrose,  test  for,  Fehling's,  52 

Xylander's,  52 
Diabetes  niellitus,  lavage  in,  120 

motor  insufficiency  and,  66 
Diarrhea,  gastrogenic,   in  carcinoma, 
522 
hydrochloric  acid  in,  170 
pancreatin  in,  176 
peptones  and,  108 
Diastase,  178 
Diastatic  ferments,  178 
Diet  in  arteriosclerosis,  491 

in  carcinoma,  512,  515,  516 

of  cardia,  524 
in  chronic  gastritis,  _372 

gastrorrhea,  337 
in  enteroptosis,  229 
in  erosions,  480 
in  gastric  disease,  77 
hemorrhage,  470 
heavv,  81 

in    motor    msumciency    ot    tirst 

degree,  397 
in  nervous  dyspepsia,  299 
in  operations  on  stomach,  206 
salt-free,    for     hyperchlorhydria, 

319  I 

in  syphilis,  501 
Dietarv'  hsts,  80 

regulations,  80  | 

Digestibihty,  definition  of,  81  I 

of  meat,  89 
Digestion,  definition  of,  17 
gastric,  22 

enzymes  in,  23 
hydrochloric  acid  in,  25 
Pawlow's  experiments  on,  22, 

25 
pepsin  in,  24 
intestinal,  28 
mastication  and,  18 
physiology  of,  17 
salivary,  18 

inhibition     of,     by     hydro- 
chloric acid,  18,  19 
Dilatation,  acute,  of  stomach,  73,  211, 
416 
treatment  of,  211,  212, 
417 
due  to  pyloric  stenosis,  massage 

in,  133 
postoperative,   acute,    lavage   m, 
119 
Dilator,  pyloric,  Einhorn's,  413 


Dimethylainidoazobenzol  test  for  free 
hydrochloric  acid,  41 
for  "reaction  of  stomach  con- 
tents, 41 
Dioxydiamidoarsenobenzol,  498 
Douches,  151 

interrupted,  151 
Scotch,  151 
stomach,  129 

Chase's  tube  for,  131,  132 
Einhorn's  apparatus  for,  130, 

131 
Richter's  method,  129 
Rosenheim's  tube  for,  129 
Turck's  tube  for,  131 
Drum-belly,  272.     See  Pneumatosis. 
Duodenal  aUmentation,  Emhorn  s,  in 

gastric  ulcer,  437 
Dyspepsia,  atonic,  hot  water  and,  99 
nervous,  259,  295 

achlorhydria  and,  310 
appendicitis  and,  296 

larvata  and,  297,  309 
cholelithiasis  and,  297 
diagnoses  of,  298 
diet  in,  299 

lactovegetable,  Wegele  s 

301 
vegetable,  300 
etiology  of,  295 
gallstones  and,  296 
gastric  secretion  in,  71 
hydrotherapeutics  in,  302 
inhibition     of     hydrochloric 

acid  in,  51 
massage  in,  134,  136,  137 
mineral  waters  in,  302 
nutrition  in,  299 
oxygen  bath  in,  149 
prognosis  of,  299 
prophylaxis  of,  299 
symptoms  of,  297,  298 
as  a  symptom  complex,  295 
treatment  of,  299  _ 
medicinal,  305 
physical,  302 
sea  water,  303 
surgical,  308 
Dyspeptine,  175 


Eclampsia,  lavage  in,  120 

Egg     protein,     nutritive     substances 

from,  113 
Eggs  in  gastric  disease,  90 
i  EhrUch-Hata  preparation,  498 
1  Einhorn's     apparatus     for     stomach 
douche,  130,  131        . 
bandage  for  enteroptosis,  24b 
I         bead  test,  59 


540 


INDEX 


Einhorn's  benzidin  test,  56 

diet  for  chronic  g;astritis,  374 
for  hj'perchlorhj'dria,  318 
dilator   in   treatment    of    cardio- 
spasm, 266 
duodenal  alimentation  in  gastric 
ulcer,  437 
bucket,  68 

in    diagnosis   of    cardio- 
spasm, 268 
pump,  437 
electrode,  142 

Lockwood's  modification  of, 
142 
modification    of    Leube-Ziemssen 
treatment  for  gastric  ulcer,  432 
P3'loric  dilator,  413 

treatment     of    pyloro- 
spasm  with,  268,  269 
stomach  bucket,  36 
test  for  permeabiUty  of  pylorus, 
67 
Electric  treatment  in  nervous  vomit- 
ing, 276 
of  stomach,  138 
Electricit}'  in  anorexia,  140 
in  atony  of  stomach,  140 
in  bulimia,  140 
extraventricular    apphcation    of, 

140 
in  gastralgia,  140 
intraventricular    application    of, 

140 
in  neuroses  of  stomach,  140 
in  ptosis  of  stomach,  140 
in  pylorospasm,  140 
treatment  by,  138 

indications  for,  140 
in  vomiting,  hysterical,  140 
nervous,  140 
of  pregnancy,  140 
Electrization,    extraventricular,    144, 
145 
intraventricular,  140 

with  Boas'  electrode,  140 
current  in,  144 
with  Einhorn's  electrode,  142 
with     Marshall's     electrode, 

143 
with     Stockton's     electrode, 

143 
with  Wegele's  electrode,  140 
Electrode,  lioas',  140 
Einhorn's,  142 
Marshall's,  143 
Stockton's,  143 
Wegele's,    140 
Electrotherapy  in  cardiospasm,  267 

in  cnteroptosis,  245 
Eisner's  adhesive  bandage  for  cntero- 
ptosis, 251 
Emesls.    See  Vomiting. 


EmoUients,  gastric,  199 
Emphvsema,  contraindication  for  lav- 
age,""  120 
Emulsion,  Russell's,  115 

sevi  compound  (Wyeth),  115 
Enema,  nutrient,  407 

Boas',  407 

Brandenburg's,  408 

Capitan's,  451 

in  carcinoma,  515 

Ewald's,  407 

in  gastric  hemorrhage,  466 
ulcer,  450 

Klopfer's,  409 

Kussmaul's,  408 

Lattier's,  408 

Leube's,  408 

Mering's,  408 

milk  and  egg,  407 

Moritz's,  408 

pancreas,  408 

peptone  and  propeptone,  407 

Riegel's,  407 

Robin's,  450 

Rosenheim's,  408 

Strauss',  408 
Enteroptosis,  220 

bandage  for,  Aaron's,  247,  248 

adhesive,  249 
Eisner's,  251 
Helfenberg's,  252 
removal  of,  250 
Rose's,  249,  250,  251 

Einhorn's,  248 

Longstreth's,  248,  249 
corsets  for,  253 

Aaron's,  254 

adjustment  of,  254 

Bardenheuer's,  253 

Landau's,  253 
degrees  of,  225 
diagnosis  of,  224 
diet  in,  229 

alcohol  in,  236 

Boas',  242 

carbohydrates  in,  235 

fats  in,  233,  234 

proteins  in,  233 

Strauss',  241 

technique  of,  233 

Zwieg's,  241 
drugs  in,  238,  239, 240 
clcctrotliprapoutics  in,  245 
etiology  of,  220,  221 
exercise  in,  242 
food  cure  in,  Boas',  237 
"forced  feeding"  in,  230 
forms  of,  221 

Gl^nard's  "belt  sign"  in,  24(5,  247 
hepatoptosis  in,  229 
heredity  in,  221 
hydro! iierapeutics  in,  238,  246 


INDEX 


541 


Enteroptosis,  hyperacidity'  in,  225 
hypcraiinieiitation  in,  230,  231 
massage  in,  242 
nephroptosis  in,  22o 
neurasthenia  and,  223 
pathology  of,  222 
petrissage  in,  243 
pregnancy  and,  2oo,  250 
prognosis  of,  229 
prophylaxis  of,  229 
sex  in,  220 
Stiller's  sign  in,  224 
symptoms  of,  222 
nervous,  223 
objective,  223 
tapotement  in,  244 
treatment  of,  229 
mechanical,  246 
medicinal,  256 
surgical,  257 
Enzymes,  action  of,  23,  24 
in  gastric  digestion,  23 
in  stomach  contents,  examination 
of,  49 
Epilepsy,  contraindication  for  lavage, 

120 
Epinephrin,  200 

Erepsin ,  29  \ 

Erosions,  477 

acute ,  477  I 

bismuth  in,  4S1 

blood  in  gastric  contents  and,  52 

chronic,  477 

diagnosis  of,  75,  479 

etiology  of,  478 

forms  of,  477 

gastric  contents  in,  75 

gastritis  and,  478 

hemorrhagic,  477 

hydrochloric  acid  in,  75 

pain  in,  479 

pathology  of,  478 

prognosis  of,  480 

silver  nitrate  in,  481 

superficial,  of  stomach,  diagnosis 

of,  from  gastric  ulcer,  425 
suprarenal  gland  in,  481 
symptoms  of,  479 
treatment  of,  480 
Eructations,  acid,  prescription  for,  351 
diagnosis  of,  271 
nervous,  270 
s3-mptoms  of,  270 
treatment  of,  271 
Erj'throdextrin  in  chronic  gastritis,  72 
Erythrodextrose,  conversion  of  starch 

into,  19 
Escalin  for  gastric  hemorrhage,  472 
Etat  mamelonne  in  chronic  gastritis, 
364 
in     motor    insufficiency     of 
second  degree,  401 


Eucasin,  112 

Eumydrin,  196 

Ewald-Boas  test  breakfast,  33 
composition  of,  33 
disadvantages  of,  33 

Ewald's  diet  for  chronic  gastritis,  373 
nutrient  enema,  407 

Excision  in  gastric  ulcer,  205,  456 

Exercise  in  enteroptosis,  242 

Expression     metliod     for     obtaining 
stomach  contents,  34 

Extracts,  meat,  value  of,  116,  117 

Extraventricular  electrization,  144, 145 

Eye  strain,  gastric  neuroses  and,  293 


Faradization,  direct,  of  stomach,  139 

intraventricular,  144 
Fat,  91 
Fats  in  carcinoma,  514 

in  diet  in  enteroptosis,  233,  234 

food  preparations  containing,  115 

in  gastric  disease,  91 

in  hyperchlorhydria,  316 
Fauces,  irritability  of,  in  lavage,  126 
Feces,  examination  of,  57 
Feeding,  ''forced,"  in  enteroptosis,  230 
Fehling's  test  for  dextrose,  52 
Ferments,  diastatic,  178 

diminution  of,  in  stomach,  signifi- 
cance of,  51 
Ferruginous  waters,  156 

indications  for,  157 
Fersan,  107 
Fever,  contraindication  for  massage, 

134 
Fibroma,  531 
Fibromyoma,  531 
Fibrous  carcinoma,  506 
Fleiner's  bouillon-wine  enema,  405 

test  meal,  34 
Flour,  aleuronat,  112 

dextrinated,  114 

finely  divided,  114 

Knorr's,  114 

legimainous,  114 
Fluid  meat,  116 
Food,  carbohydrates  in,  77 

composition  of,  77,  78 

cure.  Boas',  in  enteroptosis,  237 

fats  in,  77 

heat  value  of,  79 

nutritive  value  of,  86 

permissible,  103 

"predigested,"  111 

preparation  of,  102 

preparations,  animal,  106 
carbohydrate,  114 
fat,  115 
milk,  116 


542 


INDEX 


Food  preparations,  mixed,  114 
stimulating,  116 
prohibited,  103 
proteins  in,  77 
quantity  of,  104 
requirement  of,  average,  86,  87 

in  calories,  86,  87 
selection  of,  102 
sleep  after,  105 
temperature  of,  105 
time  of,  in  stomach,  82,  83 
•'Forced  feeding"  in  enteroptosis,  230 
Friedenwald   and   Ruhrah's   diet   for 
chronic   gastritis, 
376 
gastrorrhea,  339 
Friedlieb's  stomach  tube,  125,  126 
Fruit,  97 


G 


Galactogen,  113 

Gallstones,    nervous    dyspepsia    and, 

296 
Galvanization,  direct,  of  stomach,  139 

intraventricular,  144 
Galvanofaradization,  intraventricular, 

144 
"Gamey"  meat,  87 
Gartner's  fat  milk,  92,  116 
Gasterine,  174 
Gastralgia,  282 

due  to  anemia,  massage  in,  135 
to  neurasthenia,  massage  in, 
135 
electricity  in  treatment  of,  140 
in  locomotor  ataxia,  285 
symptoms  of,  282 
treatment  of,  283 
Gastralgokenosis,  288 
Gastrectasis,    motor    insufficiency    of 

second  degree  and,  400 
Gastrectomy  in  carcinoma,  510 
Gastric  analvsis,  indirect  methods  of, 
61 
anodynes,  193 
antiseptics,  197 
atony,  73,  74 
carcinoma,  503 

crises  in  locomotor  ataxia,  285 
digestion,  22 
dilatation,  73 
emollients,  199 
fever,  353 
hemorrhage,  460 

adrenalin  for,  469 
analgesics  in,  473 
arteriosclerosis  and,  487 
atropine  in,  473 
bismuth  for,  471 
fhloroforiii  in,  473 


Gastric  hemorrhage,  diagnosis  of,  460 
differential,  461 
diet  for,  470 
escalin  for,  472 
gastric  ulcer  and,  460,  461 
gelatin  for,  467 
hematemesis  and,  460 
lavage  for,  471 
melena  and,  460,  462 
oil  cure  for,  471 
orthoform  in,  474 
prescriptions  for,  467 
prophylaxis  of,  462 
silver  nitrate  for,  472 
stypticin  for,  468 
treatment  of,  462 

bj'  enemata,  466 
hemostatics  in,  466 
by  lavage,  463 
medicinal,  466 
operative,  476    • 
hyperesthesia,  286 
insufficiency,  lactic  acid  in  stom- 
ach contents  and,  47 
juice,  acidity  of,  25 
action  of,  27 
color  of,  25,  38 
consistency  of,  38 
determination  of,  37 

Alatthieu's  formula  for, 
38 
hpase  in,  27 
nervous  control  of,  25 
normal,  25 
odor  of,  25,  38 
pepsin  in,  26 
rennin  in,  27 
sarcinae  in,  70 
secretion  of,  26 
specific  gravity  of,  25 
in  stomach  contents,  37 
neuroses,  259 
secretion,  alcohol  and,  188 

changes   in,    due    to    patho- 
logic conditions,  71 
sedatives,  191 
tetany,  212 

lavage  in,  119 
ulcer,  418 

age  and,  420 
appetite  in,  424 
arteriosclerosis  and,  487 
bismuth  for,  184,  443 
blood     in     gastric     contents 

and,  52 
chronic  gastrorrhea  and,  335 
cicatrization  in,  420 
complications  of,  424 
contraindication      for     mas- 

sago,  134 
diagnosis  of,  75,  425 

from  acute  gastritis,  425 


INDEX 


543 


Gastric  ulcor,  diagnosis  of,  froin   {gas- 
tric faiiccr,  426 
from    hystorictil    vomit- 
ing, 425 
from  nervous  vomiting, 

425 
from  superficial  erosion 
of  stomach,  425 
diet  in,  428 

duodenal     alimentation     in, 
Kinhorn's,   437 
procedure  of,  439 
excision  of,  205 
frequency  of,  420 
gastric  contents  in,  75 

hemorrhage    and,     460, 
461 
gastroenterostomy  in,  205 
heaUng  of,  420 
hematemesis  in,  423 
hemorrhage  in,  207,  422 
lavage  in,  119 
surgery  of,  207 
Weber's  test  for,  423 
hydrochloric  acid  in,  75 
nutritive  enema  in,  450 
Capitan's,  451 
Robin's,  450 
occult  blood  and,  53 
olive  oil  for,  448 
pain  in,  421 

epigastric,  422 
pathology  of,  418 
perforation  in,  208,  418,  423 
frequency  of,  424 
surgery  of,  209 
prognosis  of,  427 
prophylaxis  of,  428 
resorcinol  for,  447 
sequelae  of,  424 
sex  and,  420 
silver  for,  445 
situation  of,  419 
sodium  bicarbonate  in,  441 
surgery  of,  204,  205 
symptoms  of,  421 
"thread  test"  for,  Einhorn's, 

426 
treatment  of,  428 

antilytic  serum  in,  451 
bacterial  vaccines  in,  452 
Lenhartz,  434,  435 
Leube-Ziemssen,  428 
Einhorn's  modifica- 
tion of,  432 
summary  of,  431 
medicinal,  440 
surgical,  454 

excision  in,  456 
gastroenterostomy 

in,  456 
indications  for,  455 


Gastric  ulcer,  vomiting  in,  422 
"Gastrin,"  26 

Gastritis,  acid,  chronic,  314.    Sec  also 
Hypcrchlorhydria. 
treatment  of,  329 
acute,  contraindication   for   min- 
eral waters,  158 
diagnosis    of,    from    gastric 

ulcer,  425 
gastric  contents  in,  72 
hydrochloric  acid  in,  72 
infectious,  353 

etiology  of,  353 
fever  in,  353 
pathology  of,  353 
symptoms  of,  353 
treatment  of,  354 
medicinal,  355 
lavage  in,  119 
simple,  346 

course  of,  347 
diet  in,  351 
emesis  in,  347 
emetics  for,  349 
etiology  of,  346 
pathology  of,  347 
prophylaxis  in,  348 
symptoms  of,  347 
treatment  of,  348 
anacid,  366 

catarrhal,  pepsinogen  in,  24 
chronic,  362 

achroodextrin  in,  72 
alcohoUsm  and,  363 
diagnosis  of,  366 
diet  in,  372 

Boas',  376,  387 
Einhorn's,  374 
Ewald's,  373 
Friedenwald    and    Ruh- 

rah's,  376 
meat  free,  375 
Riegel's,  384 
Wegele's,  375,  386 
Zweig's,  386,  387 
erythrodextrin  in,  72 
etat  mamelonne  in,  364 
etiology  of,  362 
gastric  contents  in,  72 
gastrosan  for,  383 
hot  water  and,  99 
hydrochloric  acid  in,  72,  377 
inhibition     of     hydrochloric 

acid  in,  51 
lavage  in,  388 
massage  in,  135 
motor  insufficiencj'  and,  66 
mucus  in,  72 
pancreatin  for,  177,  380 
papain  for,  380 
papayotin  for,  380 
pathology  of,  363 


544 


INDEX 


Gastritis,  chronic,  pepsinogen  in,  72 
prognosis  of,  368 
rennin  zymogen  in,  72 
resorcinol  for,  383 
stomacMcs  for,  380 
subacidity  in,  367 
symptoms  of,  365 
treatment  of,  371 
medicinal,  377 
with  mineral  waters,  390 
physical,  391 
erosions  and,  478 
lavage  in,  119 
phlegmonous,  357 

alcohohsm  and,  358 
course  of,  360 
diffuse,  358 
etiology  of,  358 
gastroenterostomy  in,  360 
gastrostomy  in,  360 
pathology  of,  359 
prognosis  of,  360 
symptoms  of,  360 
treatment  of,  360 
polyposa,  364 
sclerotic,  364 
subacid,  366 
toxic,  246,  355 

etiology  of,  355 
pathology  of,  356 
prognosis  of,  356 
symptoms  of,  356 
treatment  of,  356 
Gastrochylorrhea,  31 

gastric  contents  in,  72 
Gastrodynia,  282.     See  also  Gastral- 

gia. 
Gastroenteroptosis,  massage  in,  245 
Gastroenterostomy  in  carcinoma,  219, 
512 
in  gastric  ulcer,  205,  456 
in  phlegmonous  gastritis,  360 
in  ulcer  of  duodenum,  206 
of  pylorus,  206 
Gastrofaradization,  139 
Gastrogalvanization,  139 
Gastrojejunostomy,  perigastritis  and, 

486 
Gastroplication  in  gastroptosis,  215 
Gastroptosis,  220.     See  also  Entero- 
ptosis. 
gastroplication  in,  215 
in    motor    insufficiency    of    first 

degree,  394 
surgery  of,  214 
vcnirotixation  in,  214 
Gastrorrfiagia,  4()0.    Sec  also  Gastric 
li(!morrliage. 
macroscopic;,  462 
manifest,  402 
visible,  462 
Gasfrorrhca,  31 


Gastrorrhea,  acute,  332 
chronic,  334 

age  and,  335 
carbohydrates  in,  338 
diagnosis  of,  336 
diet  in,  337 

Friedenwald   and    Ruh- 

rah's,  339 
Hquid  in,  340 
number  of  meals  in,  340 
Wegele's,  339 
etiology  of,  335 
examination,     external,     of 

stomach  in,  336 
gastric  ulcer  and,  335 
lavage  in,  342 
meat  in,  338 
"milk  cm-e"  in,  340 
mineral  waters  in,  343 
Murphy's  proctoclysis  in,  337 
prognosis  of,  337 
symptoms  of,  335 
treatment  of,  337 
medicinal,  341 
physical,  343 
surgical,  343 
gastric  contents  in,  72 
intermittent,  332 
Gastrosan  for  chronic  gastritis,  383 
Gastrostomy,  indications  for,  204 
in  phlegmonous  gastritis,  360 
Gastrosuccorrhea,  31,  332.     See  also 
Hypersecretion, 
gastric  contents  in,  72 
Gastroxynsis,  nervous,  333 
Gelatin,  89 

for  gastric  hemorrhage,  467 
preparation  of,  89 
Gelatinous  carcinoma,  506 
Geneva  lithia  water,  analysis  of,  161 
Glcnard's  "belt  sign"  in  enteroptosis, 

246,  247 
Globon,  113 
Glycogen,  conversion  of,  by  ptyalin, 

18 
Graham  bread,  95 
Great  Jiear  ^^'ater,  analysis  of,  159 
Gruel  soups,  96 
Guaiac   test,    Weber's,    for   blood    in 

gastric  contents,  53 
Giinzburg's  test  for  absorptive  powers 
of  stomacii,  61,  62 
for  free  liydrochloric  acid,  41 
for  reaction  of  stomach  con- 
tents, 41 


Hauersuon's    diet     for     hyperchior- 

hydria,  3  IS 
Hal)ilns  cnteropticus,  221 


INDEX 


545 


Hathorn  water,  analysis  of,  103 
Heart  in  arteriosclerosis,  490 

disease,  contrainiiication  for  lav- 
age, 120 
Heat,    application    of,    to    abdominal 

region,  loO,  151 
Helfenberg's    aclhesi\e    bandage    for 

enteroptosis,  252 
Heraatemesis,  gastric  lieinorrhage  and, 
460 
in  gastric  ulcer,  423 
hemoptysis  and,  32 
lavage  in,  119 
Hemmeter's   directions    for   massage, 

135 
Hemoptysis,  hematemesis  and,  32 
Hemorrhage,  gastric,  460 
in  gastric  ulcer,  207 
recent,  contraindication  for  lav- 
age, 120 
Hemorrhagic  erosions,  477 
Hemostatics  in  treatment  of  gastric 

hemorrhage,  466 
Hpi)atoptosis,  220 
diagnosis  of,  229 
in  enteroptosis,  229 
Hernia  epigastrica,  531 

symptoms  of,  532 
treatment  of,  532 
Heterochylia,  71 
Heyden's  nutritive,  113 
Hiccough,  281.    See  Singultus. 
"Hormones,"  26 
Hot  cataplasms,  151 
compre.s.ses,  150 
Hourglass   contraction,    diagnosis   of, 
214 
perigastritis  and,  482 
surgery  of,  214 
Hydriatic  treatment  of  stomach,  146 
Hydrochloric  acid,  166 

in  achylia  gastrica,  170 
administration    of,    capsules 
for,  172,  173 
with  pepsin,  168,  171 
time  for,  167 
in  carcinoma,  217 
combined,  Topfer's  test  for, 

46 
conversion  of  sugar  by,  25 
dilution  of,  172 
dosage  of,  175 
effect  of,  on  appetite,  171 
on  bile,  170 

on  pancreatic  juice,  170 
on  proteins,  169 
on  secretions,  168 
in  erosions  of  stomach,  75 
free,  Congo  red  test  for,  40, 
41 
dimethylamidoazoben- 
zol  test  for,  41   s 
35 


Hydrochloric    acid,   free,    Giinzburg's 
test  for,  41 
phloroglucin-vanillin 

test  for,  41 
T()pfer's  method  for  ana- 
lysis of,  45 
in  gastric  carcinoma,  75 
digestion,  25 
ulcer,  75 
in  gastritis,  acute,  72 
chronic,  72,  377 
in  gastrogenic  diarrhea,  170 
in  hj'persecretion,  72 
indications  for,  171 
inhibition  of,  in  chronic  gas- 
tritis, 51 
during       menstruation, 

51 
in  nervous  dyspepsia,  51 
of  salivary  digestion  bv, 
18,  19 
pepsin  and,  24,  26,  49 
proteoly.sis  and,  168,  169 
in  pyloric  insufficiency,  75 
secretin  and,  168 
Hydrocyanic  acid,  diluted,  192 
Hydrogen  peroxide,  198 

in  hyperchlorhydria,  323 
Hydrotherapeutics,  146 
cold  entire  pack,  148 
in  enteroptosis,  238,  246 
half  baths,  147 
indications  for,  149 
prolonged  baths,  149 
"rub  off"  in,  147 
skin  reaction  in,  147 
temperature  of  water  in,  146 
warm  entire  pack,  148 
wet  rub  in,  146 
Hygiama,  114 

Hyperacidity,  311.     See  also  Hyper- 
chlorhydria. 
in  enteroptosis,  225 
gastric  contents  in,  71 
in    motor    insufficiency    of    first 

degree,  diet  in,  397 
treatment  of,  329 
Hyperalimentation,  230,  231 
in  enteroptosis,  230,  231 
Hyperchlorhydria,  311 

contraindication     for     massage, 

134 
diagnosis  of,  313 
diet  in,  Einhom's,  318 
Habershon's,  318 
salt-free,  319 
Strauss',  317 
digestion  of  starch  in,  52 
etiology  of,  312 
gastric  contents  in,  71 
lavage  in,  328 
medication  in,  course  of,  328 


546 


INDEX 


H3-perchlorhyflria,  pathologj^  of,  312 
physiotherapeutic    measures    in, 

329 
prognosis  of,  314 
sugar  in,  98 
symptoms  of,  313 
treatment  of,  alkahes  in,  325 
alkaloids  in,  324 
analgesics  in,  324 
astringents  in,  320 
atropine  in,  322 
bismuth  in,  320,  321 
carbohydrates  in,  315 
Carlsbad  salt  in,  326,  327 
dietetic,  315 
fats  in,  316 

hydrogen  peroxide  in,  323 
hygienic,  314 
medicinal,  320 
oils  in,  316 
proteins  in,  315 
salts    of   aikahne   earths   in, 

325 
silver  in,  320,  321 
Hvperemesis   gravidarum,    treatment 

of,  274,  275 
Hyperesthesia,  gastric,  286 
etiologj'  of,  286 
nitrate  of  silver  in,  287 
symptoms  of,  286 
treatment  of,  286 
Hypermotiht}-,  260 

in  achylia  gastrica,  260 
Hyperorexia,  289.     See  also  Bulimia. 
Hj'persecretion,  31 
alimentarj',  343 

diagnosis  of,  344 
symptoms  of,  344 
treatment  of,  345 
lavage  in,  345 
medicinal,  345 
chronic,  335.     See  also  Gastror- 

rhea,  chronic, 
contraindication    for   massage  of 

stomach,  134 
diagnosis  of,  72 
gastric  contents  in,  72 
hydrochloric  acid  in,  72 
intermittent,  332 

diagnosis  of,  333 
etiology  of,  332 
headaches  in,  333 
nervous  system  and,  332 
symptoms  of,  332 
treatment  of,  333,  334 
in    motor    insufficiency    of    first 

degree,  diet  in,  397 
periodic,  332 
Hypertrophic     stenosis    of    pylorus, 

212 
Hysteria,  contraindication  for  lavage, 
120 


Ice  water,  98 

Infectious  acute  gastritis,  353 
catarrh  of  stomach,  353 
Inspection  of  stomach  contents,  36 
InsuflBciencj^     motor,     anemia     and, 
66 
bulimia  and,  67 
chlorosis  and,  66 
chronic  catarrh  and,  66 
congenital,  66 
diabetes  and,  66 
diagnosis  of,  73 
of  first  degree,  393 

acidity  in,  normal, 

diet  in,  397 
anaciditv    in,    diet 

in,  397 
atony  and,  394 
diagnosis  of,  395 
etiologj-  of,  393 
gastropto.?is  in,  395 
hj-peracidity         in, 

diet  in,  397 
hj-persecretion     in, 

diet  in,  397 
lavage  in,  398 
myasthenia        and, 

394 
"stomach         dizzi- 
ness" in,  394 
subacidity   in,   diet 

in,  397' 
sjTnptoms  of,  394 
treatment  of,  396 
medicinal,  399 
milk,  396 
with      mineral 

waters,  400 
physical,  399 
gastric  contents  in,  73 
leukemia  and,  66 
mineral  waters  and,  157 
myasthenia  and,  66 
neurasthenia  and,  67 
paresis  and,  66 
polyphagia  and,  67 
of  second  degree,  400 

diagnosis  of,  402 
dilatation  and,  400 
etat  mameloune  in, 

401 
etiology  of,  400 
gastrectasis        and, 

400 
isrhochvmia      and, 

400 
pyloric  stenosis  and, 

401 
rectal    alimentation 
in,  404 


INDEX 


547 


Insufficiency,  motor,  of  second  (lefuree, 
subcutaneous  nutri- 
tion in,  410 
symptoms  of,  402 
treatment  of,  403 
by  lavage,  410 
medicinal,   412 
with      mineral 

waters,  412 
physical,  412 
pyloric  stenosis 
in,  413 
syphilis  and,  66 
tuberculosis  and,  66 
urine  in,  73 
pyloric,  279 

diagnosis  of,  74 
etiology  of,  279 
gastric  contents  in,  75 
hj'drochloric  acid  in,  75 
treatment  of,  279 
Intermittent  gastrorrhea,  332 

hypersecretion,  332 
Interrupted  douches,  151 
Intestinal  obstruction,    contraindica- 
tion for  mifferal  waters,  158 
lavage  in,  118 
paresis,  lavage  in,  119 
Intestine,  large,  absorption  of  proteins 

by,  406 
Intraventricular  electrization,  140 
faradization,  144 
galvanization,  144 
gah'anofaradization,  144 
Invertin,  29 

Iodides  in  arteriosclerosis,  492 
Iodine,  198 

reaction  in  achlorhydria,  52 
Ischiochymia,  carcinoma  and,  511 

motor    insufficiency     of     second 
degree  and,  400 
Isomaltose,  conversion  of  starch  into, 
18 


Jacoby-Solms'  method  of  determina- 
tion of  pepsin,  49 
Jacques  patent  tubes  for  lavage,  121 
Jelly,  meat,  89 
Juices,  meat,  value  of,  117 


Karno,  116 
Kefir,  92,  93,  116 

composition  of,  93 

preparation  of,  93 

value  of,  93 
Kinases,  24 
Klopfer's  nutrient  enema,  409 


Knorr's  flours,  114 
Koumiss,  92,  93,  116 

composition  of,  93 

preparation  of,  93 

value  of,  93 
Kreatinin  in  meat,  87 
Kussmaul's  nutrient  enema,  408 


Lactic  acid   bacilli,  carcinoma    and, 
509 
sarcoma  and,  529 
Boas'  test  breakfast  and,  33 
in  carcinoma,  75,  217,  509 
in  meat,  87 
in  pyloric  stenosis,  74 
sarcoma  and,  529 
in  stomach  contents,  47 
Lactose,  29 

Lactovegetable  diet  in  nervous  dys- 
pepsia, 301 
"Lana,"  91 

Landau's  corset  for  enteroptosis,  253 
Laparotomy  in  carcinoma,  217,  509 
Lattier's  nutrient  enema,  408 
Lavage,  118 

in  acute  gastritis,  119 

in     alimentary     hypersecre- 
tion, 345 
apparatus  for,  121 
breathing  in,  127,  128 
in  Bright's  disease,  120 
in  carcinoma,  516 
of  cardia,  525 
in  chronic  gastritis,  388 

gastrorrhea,  342 
in  cicatricial  closure  of  pylorus, 

119 
contraindications  for,  120 
bronchitis,  120 
cachexia,  120 
emphysema,  120 
epilepsy,  120 
fever,  120 
gastric     ulcer     mth     recent 

hematemesis,  120 
heart  disease,  120 
hemorrhage,  recent,  120 
hysteria,  120 
marked  prostration,  120 
neurasthenia,  120 
pregnane}',  120 
pulmonary  tuberculosis,  120 
in  convulsions  from  overfeeding, 

119 
in  diabetes  meUitus,  120 
in  dilatation,  acute  postoperative, 

119 
duration  of  treatment  by,  128 
in  eclampsia,  120 


548 


INDEX 


Lavage  in   gastric   hemorrhage,   463,  \ 
471  I 

tetany,  119 
in  gastritis,  119 
in  hematemesis,  119 
in  hemorrhage  from  gastric  ulcer, 

119 
in  hjijerchlorhydria,  328 
indications  for.  118 
in  intestinal  obstruction,  118 

paresis,  119 
irrigator  for,  121,  123 
irritabiht}'  of  fauces  in,  126 
Jacques  patent  tubes  in,  121 
in   meteorism   of   t^'phoid   fever, 

119 
in    motor    insufficiencj'    of    first 
degree,  398 
of  second  degree,  410       | 
nausea  in,  prevention  of,  126  ' 

in  ner\-ous  vomiting,  276 
in  poisoning,  118 
in  simple  atony.  118 
in  stenosis  of  pvlorus,  with  dilata- 
tion. 118,  119 
technique  of,  121 
time  for,  128 
tubes  for,  122,  123 
in  vomiting  from  peritonitis,  119 
postoperative,  119 
uncontrollable,  119 
Legumes,  97 
Leguminous  flours,  114 
Leiter's  coils,  151 
Lenhartz  treatment  for  gastric  ulcer, 

434,  435 
Lentils,  97 

Leo's  test  for  rennhi,  50 
Leube's  diet  li.sts,  86 
nutrient  enema,  408 
test    meal   for   determination   of 
motor  function  of  stomach,  66 
Leube-Ziemssen  treatment  for  gastric 

ulcer,  428 
Leukemia,  motor  insuflRciencj-  and,  66 
Liebig-Kemmerich's  meat  extract,  116 
Lin.seed  poultice,  150 
Lipanin,  116 
Lipase,  29 

in  gastric  juice,  26 
Lipoma,  531 
Locomotor  ataxia,  gastralgia  in,  285 

gastric  crises  in,  285 
Lofflund's  cream  conserve,  116 
Londonderry  lithia  water,  analysis  of, 

165 
Longstreth's  bandage  for  enteroptosis, 

248,  249 
Lugol  solution,  composition  of,  52 

conversion  of  starch  and,  19, 
52 
Lysins  in  carcinoma,  65 


M 


Macroscofic  gastrorrhagia,  462 
Maggi's  bouillon,  116 

condiment,  116 
Malignant    growth,    contraindication 

for  mineral  waters,  157 
Maltase,  29 

conversion  of  starch  into,  18 
Manifest  gastrorrhagia,  462 
Manitou  water,  analysis  of,  161 
jMarshall's  electrode,  143 
Mashed  potato  poultice,  150 
Massage,  133 
age  and,  134 
in  chronic  constipation,  138 

gastritis,  135 
contraindications  for,  134 
carcinoma,  134 
fever,  134 
gastric  ulcer,  134 
hyperclilorhydria,  134 
hypersecretion,  134 
meteorism,  134 
ulcer  with  adhesions,  134 
Crede's  method  of,  136 
in     dilatation     due     to     pyloric 

stenosis,  133 
in  enteroptosis.  242,  245 
in  gastralgia,  135 
Hemmeter's  directions  for,  135 
indications  for,  133 
in  inert  musculature,  133 
lubrication  for,  137 
medication  in,  137 
in  nervous  dyspepsia,  134,  136 
petrissage  in,  135 
in  primarj'  intestinal  atony,  134 
in  retention  of  gastric  contents, 

133 
tapotement  in,  135 
technique  of,  135 
time  for,  135 
vibratory,  137 
Mastication,  digestion  and,  18 

slow,  importance  of,  104 
Matthieu's  formula  for  determination 

of  gastric  juice,  38 
Meals,  test,  32 
Meat,  87 

broth,  nutritive  value  of,  90 
canned,  88 
composition  of,  87 
dark,  87 

digestibility  of,  89 
extracts,  composition  of,  116,  117 
Liebig-Kemmerich's,  116 
Toril,  116 

value  of,  relative,  116,  117 
fluid,  116 

free  diet  for  chronic  gastritis,  375 
"gamcy,"  88 


INDEX 


549 


Meat  jelly,  89 

juice,  Valentine's,  IIG 

Wyeth's,  116 
kreatinin  in,  87 
lactic  acid  in,  87 
preparation  of,  88 
quantity  of,  required,  88 
raw,  88 

trichinosis  and,  88 
salted,  88 
smoked,  88 

varieties  of,  i)erniissible  for  gas- 
tric patients,  89 
white,  87 
xanthin  in,  87 
Medullary  carcinoma,  506 
Melena,  gastric  hemorrhage  and,  460, 

462 
Menstruation,    inhibition    of    hydro- 
chloric acid  during,  51 
Mering's  "Kraft"  chocolate,  116 

nutrient  enema,  408 
Merycism,  277.    See  Rumination. 
Meteorism,  contraindication  for  mas- 
sage, 134 
of  typhoid  fever,  lavage  in,  119 
Mett    test    for    pepsin    in    stomach 

contents,  50 
Miliary  tuberculosis,  501 
Milk,  91 

cure  in  chronic  gastrorrhea,  340 
diet  in  carcinoma,  513 
egg  and,  nutrient  enema,  407 
food  preparations  from,  116 
■     Gartner's  fat,  116 
in  gastric  disease,  91 
"phobia"  for,  91 
protein,  preparations  of,  112 
somatose,  113 
treatment  of  motor  insufficiency 

of  first  degree,  396 
value  of,  91 
vegetable,  116 
Voltmer's  mother's,  116 
Yoghurt,  93 
Mineral  baths,  158 
waters,  153 

alkaline  carbonated,  156 

chlorine,  153 
American,  159 
analyses  of,  159 
.AJlouez,  162 
Blue  Lick,  162 
Champion,  163 
Congress,  165 
Crockett   Arsenic-lithia, 

1.59 
Deep  Rock,  160 
Geneva  lithia,  161 
Great  Bear,  159 
Hathorn,  163 
Londonderry  lithia,  165 


Mineral  waters,  aiialy.ses  of,  Manitou, 
161  " 
Missisquoi,  164 
Tate  Epsom,  160 
Vichy,  164 
bitter,  157 
in  carcinoma,  518 
in  chronic  gastritis,  390 

gastrorrhea,  343 
classification  of,  1.53 
constituents  of,  153 
contraindications  for,    157 
acute  gastritis,  158 
gastro-intestinal    tuber- 
culosis, 158 
hemorrhagic  conditions, 

157 
intestinal    obstruction, 

1.58 
malignant    growth,    157 
motor  insufficienc}',  157 
ferruginous,  156 
in  motor  insufficiency  of  first 
degree,  400 
of    second    degree, 
412 
sodium  chloride,  155 
Mintz's  method  of  analysis  of  stomach 

contents,  45 
Missisquoi  water,  analysis  of,  164 
Moritz's  nutrient  enema,  408 
Morphine  poisoning,  lavage  in,  118 
Motor  function  of  stomach,  66 

neuroses,  259 
Mucous  membrane  shreds  in  gastric 
contents,  71 
polypi,  531 
Mucus  in  chronic  gastritis,  72 

in  stomach,  31 
Murphy's  proctoclysis  in  chronic  gas- 
trorrhea, 337 
Musculature,  inert,  massage  in,  133 
Mushrooms,  97 
Mutase,  112 
Myasthenia,    motor    insufficiency    of 

first  degree  and,  66,  394 
Myer's  dilator  in  treatment  of  cardio- 
spasm, 265,  266 


N 


Narcotics  in  carcinoma,  521 
Nausea  in  carcinoma,  507 

in  lavage,  prevention  of,  126 
nervous,  288 

etiology  of,  288 
treatment  of,  289 
Nephroptosis,  220 
diagnosis  of,  225 

by  palpation,  225 
positions  for,  226,  227,  228 


550 


INDEX 


Nephroptosis  in  enteroptosis,  225 
Xervous  affections  of  stomach,  259 

anorexia,  291 

dyspepsia,  259,  295 

eructations,  270 

gastroxjTisis,  333 

nausea,  288 

vomiting,  273 
Xeubauer  and  Fisher's  test  for  gastric 

carcinoma,  63,  64 
Neuralgia  of  stomach,  282.     See  also 

Gastralgia. 
Neurasthenia,     contraindication    for 
lavage,  120 

enteroptosis  and,  223 

gastralgia  due  to,  massage  in,  135 

gastrica,    295.      See    Dyspepsia, 
nervous. 

motor  insufficiency  and,  67 
Neinroses,  71,  259 

electricity  in  treatment  of,  140       ; 

eye  strain  and,  293  I 

motor,  259  I 

secretory,  311  ' 

sensory,  282 
Nitroglycerin,  192 
Normal  solutions,  42,  43 
Nutrient  enema,  407 
Nutrition,    subcutaneous,    in    motor 

insufficiency  of  second  degree,  410 
Nutritive-Heyden,  113 
Nutrole,  115 
Nutrose,  112 
Nylander's  test  for  dextrose,  52 


Obstruction,   intestinal,    lavage    in, 

118 
Occult  blood,  53 
Odda,  115 

Oil  cure  for  cardiospasm,  264 
for  gastric  hemorrhage,  471 
olive,  199 

effects  of,  199,  200 
in  gastric  ulcer,  448 
of  sesame,  115 

treatment    of    hyperchlorhydria, 
316 
of  pylorospasm,  270 
Orexin,  189 
Orthoform,  193,  194 

for  gastric  hemorrhage,  474 
(Overeating,  arteriosclerosis  and,  488 
Overwork,  arteriosclerosis  and,  488 
Oxygen  baths,  149 


Pack,  cold,  148 
warm,  14S 


Pancreas  nutrient  enema,  408 
Pancreatic  secretion,  28 

composition  of,  29 
effect    of    hydrochloric    acid 
on,  170 
Pancreatin,  175 

administration  of,  177 

in  chronic  gastric  catarrh,  177 

gastritis,  380 
constituents  of,  176 
in  gastrogenic  diarrhea,  176 
indications  for,  176,  177 
preparation  of,  176 
properties  of,  176 
Pankreon,  177 
Papain,  178 

for  chronic  gastritis,  380 
Papayotin,  178 

for  chronic  gastritis,  380 
Parapeptone,  27 
Paresis,  intestinal,  lavage  in,  119 

motor  insufficiencj^  and,  66 
Parietal  cells  of  stomach,  24 
Parotid  gland,  secretion  of,  18 
Pawlow's  experiments  on  gastric  diges- 
tion, 22,  25 
Peas,  97 
Pequin,  92 

Penzoldt's  diet  lists,  81-85 
Pepsin,    24,    166.      See    also    Hydro- 
chloric acid, 
administration  of,  168 
in  carcinoma,  217 
in  gastric  digestion,  24 

juice,  26 
hvdrochloric    acid    and,    24,    26, 

"49 
in  stomach  contents,  determina- 
tion of,  49 
Jacoby  -  Solms 
method  of,  49 
Mett  test  for,  50 
ricin  test  for,  49 
Pepsinogen,  24 

in  carcinoma,  24 
in  catarrhal  gastritis,  24 
in  chronic  gastritis,  72 
iiydrochloric  acid  and,  49 
Peptic  cells  of  stomach,  24 

ulcer,  418.    See  also  Gastric  ulcer. 
Peptone.s,  24,  27,  107_ 
albumoses  in,  107 
alcohol  in,  109,  110 
calorics  in,  109,  110 
cost  of,  110,  HI 
diarrhea  and,  lOS 
food  value  of,  109,  1 10 
nutritive  value  of,  107 
propeptone  nutrient  enema,  and 

407 
taste  of,  108 
lest  for,  51 


INDEX 


551 


Perforating   gastric   ulcer,   418.     See 

also  Gastric  ulcer. 
Perforation  in  carcinoma,  507 

in  gastric  ulcer,  208 
Perigastritis,  213,  482 

diagnosis  of,  214,  484 

from  carcinoma,  484 
with  formation  of  tumors,  483 
forms  of,  483 

gastrojejunostomy  and,  486 
hour-glass  stomach  and,  482 
with  local  adhesive  growths,  483 
pain  in,  484 
prophylaxis  of,  485 
pyloroplasty  and,  486 
surgery  of,  214 
treatment  of,  485 
Periodic  hypersecretion,  332 
Peristalsis,  effect  of  strj-chnine  on,  187 

of  stomach,  20,  21 
Peristaltic  unrest,  260 

symptoms  of,  260,  261 
treatment  of,  261 
Peritonitis,  vomiting  from,  lavage  in, 

119 
Permeability  of  pylorus,  67 
Petrissage  in  enteroptosis,  135,  243 
Pfund's  cream  protein  mixture,  116 
Phenol,  197 

Phlegmonous  gastritis,  357 
Phenolphthalein  test  for  occult  blood, 
56,  57 
for  total  acidity  of  stomach 
contents,  44 
Phloroglucin-vardllin     test     for     free 
hydrochloric  acid,  41 
for  reaction  of  stomach  con- 
tents, 41 
Pilocarpine,  196 
Pineapple  juice,  178 
Plasmon,  113 
Plummer's    dilator    in    treatment    of 

cardiospasm,  266 
Pneumatosis,  272 

treatment  of,  272 
Poisoning,  lavage  in,  118 
Polyphagia,    motor    insufficiency    of 

stomach  and,  67 
Polypi,  mucous,  531 
Potatoes,  96 
Poultice,  mashed  potato,  150 

Unseed,  150 
" Predigested"  foods.  111 
Pregnancy,  contraindication  for  lav- 
age, 120 
enteroptosis  and,  255,  256 
Priessnitz  bandage,  151 
Proctoclysis,    Murphy's,    in     chronic 

gastrorrhea,  337 
Proenzymes,  24 
Prolonged  baths,  149 
Propeptone,  27 


Propeptone,  test  for,  51 
Prostration,  contraindication  for  lav- 
age, 120 
Protalbumoses,  27 

Proteins,     absorption     of,     bj^     large 
intestine,  406 
action  of  stomach  on,  21 
animal,  preparations  of,  106 
in  diet  in  enteropto.sis,  233 
effect    of    hydrochloric    acid    on, 

169 
egg,    nutritive   substances    from, 

113 
milk,  preparations  of,  112 
mixture,  Pfund's  cream,  116 
in  treatment  of  hyperchlorhvdria, 

315 
vegetable,  preparations  of,  112 
Proteolvsis,   hydrochloric  acid  and, 

168,  169 
Protogen,  113 

Protozoa  in  gastric  contents,  70 
Psychotherapeutics  in  nervous  vomit- 
ing, 277 
in  rumination,  277 
Ptosis  of  stomach,  electricity  in  treat- 
ment of,  140 
Ptyalin,  IS 

Pulmonary     tuberculosis,   contraindi- 
cation for  lavage,  120 
Pump,  stomach,  34 
"  Pumpernickle, "  95 
Pus  in  stomach,  32 
Pylorectomy  in  carcinoma,  510 
Pyloric  dilator,  Einhorn's,  413 
insufficiency,  279 

strychnine  in,  187 
stenosis,  74,  209 
Pyloroplasty,  perigastritis  and,  486 
Pylorospasm,  267 
diagnosis  of,  268 

Einhorn's    duodenal    bucket 
in,  268 
electricity  in  treatment  of,  140 
etiology  of,  267 
treatment  of,  268 
drug,  270 

wdth  Einhorn's  pyloric  dila- 
tor, 268,  269 
oil,  270 
Pylorus,  cicatricial  closure  of,  lavage 
in,  119 
insufficiency  of,  279 
permeabiUty  of,  67 

Einhorn's  test  for,  67 
PjTOsis,  prescription  for,  351 


Q 


Quin'ton's  law,  303 


ooJ 


INDEX 


B 


Raw  meat,  88 

Rectal    alimentation    in    motor    in- 
sufficiency of  second  degree,  404 
Regurgitation,  278 
Reichman's    disease,    31,    334.      See 

also  Gastrorrhea,  chronic. 
Rennin,  action  of,  27 

curdling  of  casein  by,  27 
in  gastric  juice,  26 
Leo's  test  for,  .50 
in  pyloric  stenosis,  74 
qualitative  test  for,  50 
zymogen,  in  chronic  gastritis,  72 
test  for,  51 
Resorcinol,  197 

in  chronic  gastritis,  383 
in  gastric  ulcer,  447 
Rice,  96 

meal,  97 
Richter's  method  for  stomach  douche, 

129 
Ricin    test    for    pepsin    in    stomach 

contents,  49 
Riegel's  diet  for  chronic  gastritis,  384 
nutrient  enema,  407 
test  dinner,  33 

meal    ifor    determination    of 
motor  function  of  stomach, 
66 
Robin's    nutrient    enema    in    gastric 

ulcer,  450 
Roborat,  112 

Roentgen  raj's  in  carcinoma,  523 
Roentgenograph}',  bismuth    salts    in, 

use  of,  183 
Rosenheim's  nutrient  enema,  408 

tube  for  stomach  douche,  129 
Rose's  adhesive  bandage  for  entero- 

ptosis,  249,  250,  251 
Round  ulcer,  418.     See  also  Gastric 

ulcer. 
Rumination,  277 
etiology  of,  277 
symptoms  of,  277 
treatment  of,  277 
drug,  278 

p.sychotherapeutic,  277 
Rupture  in  carcinoma,  507 
Russell's  emul.sion,  115 
Rye  bread,  95 


S 


Sahli's  desmoid  test,  62 

Salicylates,  198 

.Saline  waters,  alkaline,  150 

Saliva,  action  of,  18 
chemical,  18 
diastatic,  19 


Saliva,  action  of,  physical,  18 
specific  gravity  of,  18 
in  stomach,  31 
Salivarj'  digestion,  18 
Salomon's  test  for  gastric  carcinoma, 

63 
Salted  meat,  88 
Salt-free    diet    for    hvperchlorhydria, 

319 
Salvarsan,  498 
Salvatose,  107 
Sanatogen,  112 
Sarcin£e  in  gastric  juice,  70 
in  p3'loric  stenosis,  74 
Sarcoma,  527 

anemia  in,  529 
cachexia  in,  529 
diagnosis  of,  530 

from  carcinoma,  530 
etiology  of,  527 
frequency  of,  527 
lactic  acid  and,  529 

bacilli  and,  529 
pathology  of,  528 
symptoms  of,  529 
treatment  of,  530 
Coley's,  530 
Schlessinger  and  Hoist's  modification 

of  benzidin  test,  55 
Schmidt's  table  of  nutritive  value  of 
foods,  86 
test  diet,  57 
Scirrhous  carcinoma,  506 
Sclerotic  gastritis,  364 
Scotch  douches,  151 
Sea  baths,  158 

Sea  water  treatment  of  nervous  dys- 
pepsia, 303 
"Secretin,"  26,  29 

hydrochloric  acid  and,  168 
Secretory  neuroses,  311 
Sedatives,  gastric,  191 
Sensor}'  neuroses,  282 
Serum,  antilytic,  treatment  of  gastric 

ulcer  with,  451 
Sevetol,  115 

Silver  in  gastric  ulcer,  445 
nitrate,  190 

action  of,  190 
dosage  of,  191 
in  erosions,  481 
in  gastric  hemorrliage,  472 
indications  for,  190 
Simple  acute  gastritis,  346 
Singultus,  281 

gastricu.s,  281 
Sippy's  dilator  in  treatment  of  cardio- 
spasm, 264,  265 
"Si.\  liuii(ircd  and  six,"  498 
Skin  reaction  in  carcinoma,  65 
Sleep  after  focxi,  105 
Smoked  meat,  .S8 


INDEX 


553 


Sodium    bicarbonate,    adniiniistration 
of,  179 
in  gastric  ulcer,  441 
chloride  as  an  emetic,  180 
waters,  155 

contraindications        for, 

156 
indications  for,  155 
Somatine,  107 
Somatose,  106 
milk,  113 
Soups,  gruel,  96 
Sour  milk,  92 
Spices,  98 
Splenoptosis,  220 

Starch,    conversion    of,    into    achroo- 
dextrin,  19 
into  amylodoxtrin,  19 
into  erythrodextrose,  19 
into  isomaltose,  18 
Lugol  solution  and,  19,  52 
into  maltose,  18 
by  ptj'alin,  18 
stages  of,  18,  19 
digestion  of,  in  hyperchlorhydria, 
52 
Stenosis,  hypertrophic,  of  pylorus,  212 
diagnosis  of,  213 
surgery  of,  213 
pjioric,  Boas-Oppler  bacillus  in, 
74 
diagnosis  of,  74,  209 
with    dilatation,    lavage    in, 

118,  119 
etiology  of,  210 
gastric  contents  in,  74 
lactic  acid  in,  74 
motor  insufficiency  of  second 

degree  and,  401 
rennin  in,  74 
sarcinse  in,  74 
surgery  of,  210,  211 
treatment  of,  413 
Stiller's  sign  in  enteroptosis,  224 
Stockton's  electrode  and  stomach  tube, 

143 
Stomach,  absorptive  power  of,  28 

Giinzburg's  test  for,  61, 
62 
arteriosclerosis  of,  487 
aspirator,  35 
bucket,  35,  36 
carcinoma  of,  503 
contents,  acidity  of,  analysis  of, 
quantitative,  43 
total,    phenolphthalein 
test  for,  44 
analysis  of,  Mintz's  method 
45 
quantitative,  42 
Topfer's  method  of,  45 
blood  in,  52 


Stomach  contents,  enzymes  in,  exami- 
nation for,  49 
examination  of,  31 
chemical,  39 
macroscopic,  34 
microscojjic,  08 
inspection  of,  36 
lactic  acid  in,  47 

carcinoma   and,    47 
gastric  insufficiency 

and,  47 
Strauss'  test  for,  48 
Uffelmann's  test  for, 
47,  48 
mucous  membrane  shreds  in, 

71 
pepsin  in,  determination  of, 
49 
Mett  test  for,  50 
Ricin  test  for,  49 
protozoa  in,  70 
reaction  of,  Congo  red  test, 
for,  40 
determination  of,  40 
dimethylamidoazoben- 

zol  test  for,  41 
Giinzburg's  test  for,  41 
phi  or  oglucin- vanillin 
test  for,  41 
retention  of,  massage  in,  133 
dilatation  of,  acute,  211,  416 
"dizziness"  in  motor  insufficiency 

of  first  degree,  394 
douche,  129 

electrical  treatment  of,  138 
erosions  of,  477 

ferments  in,  diminution  of,  signi- 
ficance of,  51 
hemorrhage  from,  460 
hydriatic  treatment  of,  146 
lavage  of,  118 
massage  of,  133 
motor  function  of,  66 

insufficiency  of,  393,  400 
movements  of,  23 
neuroses  of,  259 
parietal  cells  of,  24 
peptic  cells  of,  24 
peristalsis  of,  20,  21 
pump,  34 
sarcoma  of,  527 
thermic  treatment  of,  146 
tube,  35 

Friedlieb's,  125,  126 
Strauss',  125,  127 
ulcer  of,  418 
undigested  food  in,  30 
Strauss'  diet  table  for  enteroptosis,  241 
for     hyperchlorhydria, 
317 
nutrient  enema,  408 
stomach  tube,  125,  127 


554 


INDEX 


Strauss'  test  for  lactic  acid  in  stomach 

contents,  48 
Stricture,  carcinoma  of  cardia  and,  525 
Strychnine,  186 

effect  of,  on  peristalsis,  187 
in  p5'loric  insufficiency,  187 
Stj'pticin  for  gastric  hemorrhage,  468 
Subacid  gastritis,  366 
Subacidity  in  motor  insufficiency  of 

first  degree,  diet  in,  397 
Subphrenic  abscess,  surgery  of,  209 
Sugar,  97,  98 

conversion    of,    by    hydrochloric 

acid,  25 
in  hyperchlorhydria,  98 
Suprarenal  gland  in  erosions,  481 
Syntonin,  27 
Syphilis,  494 

arteriosclerosis  and,  488 

diagnosis  of,  494 

diet  in,  501 

forms  of,  494 

motor    insufficiency    of    stomach 

and,  66 
salvarsan  for,  498 
treatment  of,  495 
general,  501 
hypodermic,  496 
Syphilitic  ulcer,  494 


Tapotement  in  enteroptosis,  244 

in  massage,  135 
Tate  Epsom  water,  analysis  of,  160 
Tea,  101 

beef,  116 
effect  of,  101 
Test,  benzidin,  Adler's  original,  55 
for  occult  blood,  54 
Schlessinger     and      Hoist's 
modification  of,  55 
Congo  red,  for  free  hydrochloric 
acid,  40,  41 
for  reaction  of  stomach 
contents,  40 
diet,  Schmidt's,  57 
dimethjdamidoazobenzol,  for  free 
hydrochloric  acid,  41 
for  reaction  of  stomach  con- 
tents, 41 
Einhorn's  bead,  59 

for  permeability  of  py- 
lorus, 67 
Fehling's,  for  dextrose,  52 
Gimzburg's,        for        absorptive 
powers  of  stomach,  61,  62 
for  free  hydrochloric  acid,  41 
for  reaction  of  stomach  con- 
tents, 41 
Leo's,  for  rennin,  50 


Test  meals,  32 

Boas',  33 

composition  of,  31,  32 
Ewald-Boas',  33 
Leube's,  for  determination  of 
motor  function  of  stomach, 
66 
Riegel's,  33 

for     determination     of 
motor     function     of 
stomach,  66 
Mett's,  for  pepsin,  50 
Mintz's,  for  analysis  of  stomach 

contents,  45 
Neubauer  and  Fisher's,  for  gas- 
tric carcinoma,  63,  64 
Nylander's,  for  dextrose,  52 
phenolphthalein,  for  occult  blood, 
56,  57 
for  total  aciditj'  of  stomach 
contents,  44 
phloroglucin-vanillin,  for  free  hy- 
drochloric acid,  41 
for  reaction  of  stomach  con- 
tents, 41 
ricin,  for  pepsin,  49 
SahU's  desmoid,  62 
Salomon's,  for  gastric  carcinoma, 

63 
Strauss',  for  lactic  acid,  48 
Topfer's,  for  analysis  of  stomach 
contents,  45 
for    combined    hydrochloric 

acid,  46 
for  free  hydrochloric  acid,  45 
Ufifelmann's,  for  lactic  acid,  47,  48 
Weber's    guaiac,    for    blood    in 
gastric  contents,  53 
Tetany,  gastric,  212 

diagnosis  of,  212 
lavage  of  stomach  in,  119 
Thermic  treatment  of  stomach,  146 
"Tliread  test,"  Einhorn's,  for  gastric 

ulcer,  426 
Thyroid  extract  in  arteriosclerosis,  493 
Tobacco,  102 

Topfer's  method  of  analysis  for  free 
hydrocliloric  acid,  45 
of  stomach  contents,  45 
test    for    combined    hydrochloric 
acid,  46 
Toril  meat  extract,  116 
Toxic  gastritis,  346,  355 
Trichinosis,  raw  meat  and,  88 
Tropon,  107 
Trunecek's  scrum   in  arteriosclerosis, 

494 
Trypsin  in  carcinoma,  523 
Trypsinogen,  29 
Tube,  slomach,  35 
Tuberculosis  ,501 
forms  of,  501 


INDEX 


bbb 


Tuberculosis,    gastro-intcstinal,    con- 
traindication for  mineral  waters, 

158 
miliary,  oOl 
motor    insufficiency    of    stomach 

and,  (it) 
pulmonary,    contraindication    for 

lavage,  120 
treatment  of,  502 
Tuberculous  ulcer,  501 
Tumors,  503 

benign,  530 
Tiirck's  tube  for  stomach  douche,  131 
Tvphoid  fever,  meteorism  of,  lavage 
'in,  119 

U 

Uffelmaxx's  test  for  lactic  acid  in 

stomach  contents,  47,  48 
Ulcer  with    adhesions,    contraindica- 
tion for  massage,  134 
duodenal,  gastro-enterostomy  in, 
206 
occult  blood  and,  54 
gastric,  418 
peptic,    418.      See    also    Gastric 

ulcer, 
perforating  gastric,  418.    See  also 

Gastric  ulcer, 
of     pylorus,     gastroenterostomy 

in,  206 
round,    418.      See    also    Gastric 

ulcer, 
syphilitic,  494 
tuberculous,  501 
Ulcus     ventricuH,     418.       See     also 

Gastric  ulcer. 
Urine  in  motor  insufficiency,  73 


Vaccines,     bacterial,     treatment     of 

gastric  ulcer  with,  452 
Valentine's  meat  juice,  116 
Vegetable  bitters,  effect  of,  188 
diastase,  178 

diet  in  nervous  dyspepsia,  300 
green,  97 
milk,  116 

proteins,  preparations  of,  112 
Ventrofixation  in  gastroptosis,  214 
Vibratory  massage  of  stomach,  137 
Vichy  water,  analysis  of,  164 
Voltmer's  mother's  milk,  116 
Vomiting  in  carcinoma,  507 

hysterical,     diagnosis     of,     from 
gastric  ulcer,  425 
electricity   in   treatment   of, 
140 
nervous,  273 

diagnosis    of,    from    gastric 

ulcer,  425 
electricity  in   treatment   of, 
140 


Vomiting,   nervous,  etiology  of,  273, 
274 
symptoms  of,  273 
treatment  of,  274 
drug,  275 
electric,  276 
lavage,  276 

p.sychotherapeutic,  277 
from  peritonitis,  lavage  in,  119 
postoperative,  lavage  in,  119 
of  pregnancy,  electricity  in,  140 
uncontrollable,  lavage  in,  119 

W 

Warm  pack,  entire,  148 
Water,  98 

artificial,  98 
ice,  98 
hot,  99 

atonic  dyspepsia  and,  99 
gastric  catarrh  and,  99 
mineral,  153 
Weber's  guaiac  test,  53 

for     blood     in     gastric 

contents,  53 
for  hemorrhage  in  gas- 
tric ulcer,  423 
Wegele's  diet  for  chronic  gastritis,  375. 
386 
gastrorrhea,  339 
electrode,  140,  141 
lactovegetable    diet    in    nervous 
dyspepsia,  301 
Wet  rub,  146 

time  for,  146 
Whey,  92 

composition  of,  92 
White  bread,  95,  96 

meat,  87 
Wines,  100 

Winternitz  coiled  tubing,  151,  152 
Wyeth's  meat  juice,  116 


Xanthin  in  meat,  87 


Yoghurt  milk,  analogous  proprietary 
preparations,  94 
compo.sition  of,  94 
preparation  of,  93 
prolongation  of  life  by,  94 
value  of,  94 


Zwieback,  95 

Zweig's  diet  for  chronic  gastritis,  386, 
.     387 

for  enteroptosis,  241 
Zymogen,  24 

rennin,  test  for,  51 


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